WELCOME

Thank you for filling out this form completely. Our goal is to help you achieve and maintain excellent dental health. The better we communicate, the better we can care for your needs. If you have any questions, we'll be glad to help!

1. ABOUT YOU

Name: Last *

First: *

Occupation:

Nickname:

Birthdate: * 🛈 +

S.S. #: *

Spouse's Name: Last

First:

Occupation:

Address: *

City: *

Zip Code: *

Sex

Male

Female

Marital Status

Home #: *

Work #:

Cell #:

E-mail address: *

Drivers License #: *

2. DENTAL INSURANCE

Do you have dental insurance? *

Yes

No

PRIMARY CARRIER

Insurance Company *

Employer Name *

Employee *

Group # *

Employee SS # *

Date of Birth * +

Date Employed * +

Contract # for ins:

Do you have secondary dental insurance? *

Yes

No

SECONDARY CARRIER

Insurance Company *

Employer Name *

Employee *

Group # *

Employee SS # *

Date of Birth * +

Date Employed * +

Contract # for ins:

GETTING TO KNOW YOU

Other family members/relatives seen by us:

Who may we thank for referring you?:

How did you hear about us? (Check all that apply) *

Have you been out of the country in the past 3 weeks? *

Yes

No

PATIENT MEDICAL HISTORY

Patient Name: *

Date of Last Exam: 🛈 +

Physician:

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

	Yes	No
1. Are you under medical treatment now?	Yes	No
2. Have you been hospitalized for any surgical operation or serious illness within the last 5 years?	Yes	No

If Yes, please explain:

	Yes	No
3. Are you taking any medication(s) including non-prescription medicine?	Yes	No

If Yes, please list any medications you are taking and the correlating diagnosis:

	Yes	No
4. Do you have sleep apnea?	Yes	No
5. Do you chew tobacco or smoke?	Yes	No
6. Do you use controlled substances?	Yes	No
7. Do you have allergies?	Yes	No

If Yes, please list your allergies:

Women Only:

	Yes	No
8. Are you pregnant/think you may be pregnant?	Yes	No
9 Are you nursing?	Yes	No
10. Are you taking oral contraceptives?	Yes	No

Do you have, or have you had, any of the following?

	Yes	No
Heart Condition/Heart Murmur	Yes	No
Rheumatic Fever	Yes	No
Epilepsy/Convulsions	Yes	No
Joint Replacement/Implants	Yes	No
AIDS or HIV infection	Yes	No
Sexually Transmitted Diseases	Yes	No
Arthritis	Yes	No
Stroke	Yes	No
Diabetes	Yes	No
Emphysema	Yes	No
Tuberculosis	Yes	No
Asthma	Yes	No
High Blood Pressure	Yes	No
Cancer/Leukemia	Yes	No
Cardiac Pacemaker	Yes	No
Kidney Disease	Yes	No
Stomach Trouble/Ulcers	Yes	No
Other	Yes	No

If Yes to "Other", please explain:

DENTAL HISTORY

Name of Previous Dentist:

Approximate Date of Last Visit: 🛈 +

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

	Yes	No
1. Do your gums bleed while brushing or flossing?	Yes	No
2. Are your teeth sensitive to hot, cold or sweet liquids or foods?	Yes	No
3. Are any of your teeth painful?	Yes	No
4. Do you have any sores/lumps in/near your mouth?	Yes	No
5. Have you had any head, neck or jaw injuries?	Yes	No

6. Have you ever experienced any of the following:

	Yes	No
Clicking	Yes	No
Pain (Joint, Ear, Side of Face)	Yes	No
Difficulty in opening/closing	Yes	No
Difficulty in chewing	Yes	No

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

	Yes	No
7. Do you have frequent headaches?	Yes	No
8. Do you clench or grind your teeth?	Yes	No
9. Do you bite your lips or cheeks?	Yes	No
10. Have you had braces/invisalign?	Yes	No
11. Do you wear dentures or partials?	Yes	No

12. What, if anything, would you change about your smile?

(check all that apply) *

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on behalf of my dependents.

CONSENT FOR TREATMENT

I hereby authorize Hudsonville Dental Associates and staff to take X-rays, study models, photos, and other diagnostic aids deemed appropriate by Dr. to make a thorough diagnosis of my dental needs.
Upon such diagnosis, I authorize Hudsonville Dental Associates to perform all recommended treatment mutually agreed upon.
I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at time of service unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a finance charge of 12% APR will be added to my account.
I have received a copy of this office’s HIPAA policy or have had the opportunity to request one.

6. I authorize Hudsonville Dental Associates to use my photographs and x-rays for research, marketing, education, or publication in professional journals. If you wish to decline the use of your photographs or x-rays for purposes other than diagnosis and treatment, please check here.

I Decline

7. Your Privacy is important to us. If you would prefer we do not discuss your dental information with immediate family members, please check here.

Do Not Discuss My Information

Patient's Signature: *

Date: * 🛈 +

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