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Please fill out and submit the form below prior to your first visit. If you prefer to print and manually fill out a PDF version of this form please click here.

Welcome to our Dental Office

The personal information provided below will be protected and keep private by our office. All information will be used and disclosed responsibly according to the Privacy Act standards set up and monitored by our office.


Address

Are you likely to be available on short notice for future appointments?
Person responsible for this account?

Address

Primary Insurance

Relation
Are You Familiar with Your plan Details?

Secondary Insurance

Relation
Are You Familiar with Your plan Details?
Method of Payment
MEDICAL HISTORY
ALL INFORMATION IS CONFIDENTIAL

The following information is required by the dentist to assist in proper diagnosis and treatment


1. Have you ever had a serious illness requiring hospitalization or extensive medical care?

2. Are you presently under the care of a physician?

3. Have you had a medical examination in the last year?
4. Do you use any prescription or non-prescription drugs regularly?
5. Do you have any allergic conditions: e.g. hay fever, skin rash, food allergies, metal, latex?
6. Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea?

7. Have you been hospitalized in the last 5 years?

8. Have you ever experienced any unusual reaction to any of the following?
9. Have you been warned against taking any drug or medication?
10. Do you bruise easily or bleed abnormally?
11. Do you require pre-medication for dental treatment?
12. Have you ever had any organ implants or medical implants?
13. Have you ever fainted?
14. Do your ankles swell?
15. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?
16. Do you have frequent headaches?
17. Do you have A.I.D.S. or have you ever tested positive for H.I.V.?
18. Do you have any of the following?

Please check any that apply

19. Have you had any injury, surgery or x-ray therapy to your face OF jaws?
20. Do you have any disease, condition, or problem that you think the doctor should know about?

21. WOMEN ONLY

Are you pregnant or suspect you might be? If so, what month are you in?
 
Are you taking birth control pills?
 
Are you nursing?

DENTAL HISTORY

1. Reason for today's visit
Are you presently having dental pain?
Is there a dental problem you would like to take care of as soon as possible?
2. How frequently do you see your dentist?
3. How often do you brush your teeth?
 
4. Do your gums bleed easily?
5. Are your teeth sensitive to:
6. Do you feel you have bad breath at times?
7. Have you ever had jaw joint surgery?
8. Do you have pain in your jaw joints or suffer from migraine headaches?
9. Does any part of your mouth hurt when clenched?
10. Does your jaw crack or pop when opened widely?
11. Have you had:
12. Do you grind or clench your teeth during the day or night?
13. Do you smoke?
14. Do you or does any family member have a problem with snoring?
15. Have you ever experienced any growths or sore spots in your mouth?

16. Previous problems with dental treatment?

17. Are you satisfied with the appearance of your teeth?

18. Other Dental Concerns

Privacy Act Notification: I have been informed of the privacy policy of this office and understand that all information I have supplied will be used and disclosed as set out within this office policy.

Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 48 hours notice, otherwise it may be necessary to charge for the time lost.

Patient Release: I, the undersigned, certify that | have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. | have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependants is mine, and I will assume responsibility for fees associated with these services.

 
(Signature)
Date

11.29.2020

 

Reviewing Dentist

Dr. Lloyd G. Pedvis Dentistry Professional Corporation

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