PATIENT INFORMATION / PARENT / SPOUSE INFORMATION
Patient Last Name: / Last Name
First Name & MI: / First Name & MI
Referred By: / Sex: / Title
Sex: / Title:
/ Birth date : (mm-dd-yy)
Birth date : (mm-dd-yy) / Age:
/ Social Security#;
Social Security: / Home Phone:
Home Phone: / Business Phone:
Business Phone: / Home Address Line 1:
Cell Phone: / Home Address Line 2:
Home Address Line 1: / City:
Home Address Line 2: / State:
City: / Driver’s License:
State & Zip / Credit Card :
Physician Name: / Billing Title:
Emergency Contact:
EMPLOYER INFORMATION / SPOUSE EMPLOYER INFORMATION
Employer: / Employer:
Address: / Address:
City: / City:
State & Zip Code: / State & Zip Code:
Phone #: / Phone #:
DENTAL INSURANCE INFORMATION
Primary Insurance Information: / Secondary Insurance Info:
Insurance Holders Name: / Secondary Insurance Holder:
Insurance Address: / Insurance Address:
City: / City:
State: / State:
Business Phone: / Business Phone:
MEDICAL HEALTH HISTORY
Circle any of the following conditions which you have now or may have had in the past:
Heart problems / ulcers or colitis / Psychiatric care / Chemotherapy
High blood pressure / Kidney problems / Diabetes / Eye disorders
Circulatory problems / Liver disease / Tuberculosis / Fainting / dizzy spells
Stroke / Hepatitis / Asthma / Tonsils removed
Heart murmur / AIDS / Respiratory disease / Adenoids removed
Rheumatic fever / HIV / Sinus problems / Unexplained weight loss
Mitral valve prolapse / Herpes / Hay fever / allergies / Venereal disease
Artificial joint / Thyroid problems / Arthritis / Rheumatism / Pain in jaw joints
Anemia / blood disease / Nervous problems / Cortisone therapy / Ear problems
Hemophilia / Epilepsy / seizures / Malignant tumor / Emotional problems
Excessive bleeding / Radiation therapy / Other:
Circle any of the following that you are allergic to:
Antibiotics / Codeine / Local anesthetic / sedatives / Other:
List all drugs that you are currently taking and amount per day:
Women: Circle any of the following that pertain to yourself:
Pregnant, What month?______Other ? explain: / Nursing / Taking birth control
DENTAL HEALTH HISTORY
Circle any of the following which you have or may have had in the past :
Bleeding gums / Bad breath / Clenching / grinding teeth / Orthodontic treatment
Swelling / lumps in mouth / Periodontal treatment / Mouth breathing / Problems for extractions
Unfavorable dental experience / Blisters / sores on lips or mouth / Oral habits like : e.g. fingernail biting / Unusual sounds in ear
Unpleasant taste / Pain around ear
Circle any of the following that you use :
Cigarettes / snuff / Pipe / cigars / Fluoride supplements or rinse
Dental floss / Water jet device / Disclosing tablets or solution
Do you at present have any dental complaints?
Circle which of the following your teeth are sensitive to:
Hot / Cold / Sweets / Chewing
Date of last visit to the dentist: Date of last X-rays:
FOR ALL PATIENTS
I have reviewed the information provided on this form and assert that it is accurate to the best of my knowledge. I understand that previous to treatment full explanation of the procedure(s) involved will be given by the doctor and or staff. I hereby assign all dental benefits to which I am entitled, including private insurance and any other dental plan, to either myself or to the party who accepts assignment. I understand that I am financially responsible to this office for all charges incurred either by myself or for the minor child for which I am seeking treatment, whether or not paid by said insurance, and that balance over 30 days will be charged a monthly service fee for witch month the balance is carried. In case of a default, I promise to pay any legal interest on balances due together with any collection costs and reasonable attorneys’ fees incurred to effect collection of this account.
______
Signature of patient (or parent if patient is a minor) Signature of insured Date
Patient name
Card member name
Card member billing address
City State Zip
Card member signature
X
Payment Authorization: Discover Mastercard Visa
Account # ______
Expiration Date______
I authorize Robert M. Judd, D.D.S. to keep my signature on file and to charge
My credit card account listed above for balance of charges not paid by insurance
Within 90 days.