TINLEY PARK DENTAL CARE CENTER

Patient Information (CONFIDENTIAL)

Name__________________________________________  Birthdate_______________ 

Social Security #____________________

Address________________________________________  City____________________ 

State____  Zip______________

Home Phone____________  Work Phone___________  E-mail___________________   Other_____________________

If Student,

Name of School/College_______________________  City_______________  State_______  

___ Full Time  ___ Part Time

Patient’s or Parent’s Employer_______________________________________________ 

Work Phone________________

Business Address______________________________________  City_______________ 

State____  Zip______________

Spouse or Parent’s Name____________________  Employer______________________ 

Work Phone________________

Whom May We Thank For Referring You?_____________________________________ 

Person to Contact in Case of Emergency?______________________________________  Relationship________________

Responsible Party information

Name of Person Responsible for this Account__________________________________

Relationship________________

Address________________________________________  City____________________ 

State____  Zip_____________

Home Phone_______________  Work Phone______________  Employer_____________________________________

Business Address__________________________________  City___________________  State____  Zip_____________

Birthdate_______________  Social Security #____________________

Financial Institution_______________________

Preferred Payment Method:  ___Cash/Check  ___Credit Card  ___Please Discuss Payment Options with Me

Insurance I

Name of Insured__________________________________

Relationship________________ Work Phone_____________________

Birthdate___________Social Security#__________________  Employer____________________ 

Business Address_______________________________  City_____________ State_________ Zip__________________

Insurance Carrier_______________ Phone______________  Group#_____________________________________

Policy ID #

Zip _______________ 

Do you have additional insurance?  ___ YES ___NO  If yes, complete the following:

Name of Insured__________________________________

Relationship________________ Work Phone_____________________

Birthdate___________Social Security#__________________  Employer____________________ 

Business Address_______________________________  City_____________ State_________ Zip__________________

Insurance Carrier_______________ Phone______________  Group#_____________________________________

Policy ID #

Zip _______________ 

PATIENT MEDICAL HISTORY

Physician_______________________________  Office Phone_________________ 

Date of Last Exam________________________

Do you have or have you had any of the following? YES   NO

Place an X in the appropriate Yes or No choice:                                            

                                              YES   NO                                             YES  NO

High Blood Pressure             ___   ___      Mitral Valve Prolapse      ___   ___      

Chest Pains                           ___  ___

Cardiac Pacemaker               ___  ___               Easily Winded          ___  ___                

Stroke                                    ___  ___

Heart Murmur                      ___  ___             Heart Attack              ___  ___              

Angina                                  ___  ___

Rheumatic Fever                  ___  ___               Fainting/Seizures      ___  ___               

Chest Pains                         ___  ___

Heart Trouble                       ___  ___               Joint Replacement    ___  ___                 

Diabetes                                ___  ___   

Hay Fever/Allergies              ___  ___                  Tuberculosis           ___  ___

Emphysema                         ___  ___

Epilepsy/Convulsions           ___  ___              Radiation Therapy     ___  ___               

Liver Disease                         ___  ___

Sexually Transmitted Disease    ___  ___  

AIDS or HIV Infection    ___  ___              

Kidney Disease                    ___  ___

Cancer                                ___  ___                Hepatitis/Jaundice      ___  ___                

Respiratory Problems         ___  ___

Recent Weight Loss           ___  ___                 Swollen Ankles          ___  ___               

Glaucoma                           ___  ___

Anemia                              ___  ___                       Arthritis                ___  ___               

Low Blood Pressure           ___  ___

Stomach Problems/Ulcers  ___  ___                       Leukemia             ___   ___ 

Other_________________________________________________________

YES  NO                

Are you allergic to any  of the following?        YES   NO

Are you under medical treatment now?          ___  ___                

Local Anesthetics (e.g. Novocaine)                 ___  ___      

Have you been hospitalized for any surgical     ___  ___

Antibiotics (e.g Penicillin)                               ___  ___

Latex Rubber                                               ___  ___

If yes, please explain:__________________________                  

Sulfa Drugs                                                   ___  ___

__________________________________________                          

Barbiturates                                                   ___  ___

Sedatives                                                      ___  ___

Are you taking any medication(s), including non-prescription ?

Iodine                                                          ___  ___

Aspirin                                                         ___  ___

Please list:________________________________                     

Metals (e.g. nickel, mercury, etc.)                     ___  ___

Have you ever taken Phen-Fen/Redux?           ___  ___                 

Other Allergies___________________       ___  ___      

Do you use tobacco?                                     ___  ___              

WOMEN;  Are you, or do you think you may be:

Do you use controlled substances?                  ___  ___                

Do you think you might be, pregnant?            ___  ___      

Do you wear contact lenses?                          ___  ___                

Are you nursing?                                           ___  ___

Are you taking oral contraceptives?                 ___  ___

Patient Dental History

Name of Previous Dentist and Location___________________________________________  

Date of Last Exam______________                                           

Do your gums bleed when brushing or flossing?           ___  ___                                 

Do you have frequent headaches?                                ___  ___                          

Are your teeth sensitive to hot or cold foods/drinks?    ___  ___                     

Do you clench or grind your teeth?                             ___  ___             

Are your teeth sensitive to sweet or sour foods?           ___  ___                                

Do you bite your lips or cheeks?                                 ___  ___                      

Do you feel pain in any of your teeth?                         ___  ___                  

Have you had any difficult extractions?                        ___  ___                

Do you have any sores or lumps in/near your mouth?  ___  ___                      

Have you ever had prolonged bleeding following         ___  ___

Have you had any head, neck or jaw injuries?                ___  ___                                                     

Have you ever experiences any of the following problems?              

Have you had orthodontic treatment?                          ___  ___         

Clicking in the jaw joint?                                             ___  ___         

Do you wear dentures or partials?                               ___  ___                       

 Pain in your jaw joint, ear, or side of face?                   ___  ___                      

 If yes, date of placement__________________

 Difficulty in opening or closing your mouth?               ___  ___                      

Have you ever received oral hygiene instructions           ___  ___

Difficulty in chewing?                                                 ___  ___                 

Do you like your smile?                                              ___  ___    

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 be or my child during the period of such Dental care to third part payers and/or health practitioners.  I authorize and request my insurance company to pay directly to the desist insurance benefits otherwise payable to me.  I understand that my dental insurance carrier may pay less than the actual bill for services.  I understand that the dentist will submit my insurance claims as a service to me, but is not a party to the insurance contract or responsible for their decisions regarding benefits.  I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of patient (or parent if minor)_________________________________________________  Date______________________