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Patient Information

Please Fill out these forms to the best of your knowledge. All answers will be kept confidential.

Date:

DOB:

 Male   Female 
 Full-Time   Part-Time 

Please tell us how you heard about us: (Check all that apply)

 My Dentist   Friend or Relative   Insurance Company   Our Website   Search Engine 
Person responsible for account. They must be present at appointment to show ID
Emergency Contact Information
Authorized Person (You are authorizing our staff to speak to this person about your account or medical needs)
Insurance Information

Primary Dental Insurance Information

Secondary Dental Insurance Information

Primary Medical Insurance Information

Secondary Medical Insurance Information

Medical History

Accurate and complete disclosure of medical information is necessary for proper diagnosis and to help prevent any unnecessarycomplication during your treatment. Please mark any condition that you have currently or have been treated for in the past.

Cardiovascular (Heart)

High blood pressureYesNo
Heart attack, congestive heart failure, angina or other heart conditionsYesNo
Damaged heart valve, heart valve replacement, heart murmurYesNo
Irregular heart beat (ie A-fib, SVT)YesNo
Swollen ankles, shortness of breath after mild exercise, chest pain on exertionYesNo
Rheumatic fever or Rheumatic heart diseaseYesNo

Endocrine

Diabetes type I or IIYesNo
Thyroid diseaseYesNo
Other endocrine diseasesYesNo

Gastrointestinal

Stomach Ulcers, Chron's disease, GERD (acid reflux), Hiatal hernia, Hyper acidityYesNo
Hepatitis, Cirrhosis, jaundice, or other liver diseaseYesNo

Hematologic (blood disorders)

Do you have a blood disorder such as hemophilia or Von Willebrands disease?YesNo
Do you bruise easily or have prolonged bleeding?YesNo
Sickle cell anemia or traitYesNo
Are you taking blood thinners (e.g., Coumadin, Plavix, Aspirin, Eliquis)?YesNo

Immunologic

Have you been diagnosed with or treated for cancer?YesNo
Chemotherapy or radiation therapyYesNo
Autoimmune disease (e.i., Sjogrens syndrome, Lupus, Rheumatoid arthritisYesNo
HIV/AIDSYesNo

Musculoskeletal

Osteoporosis/OsteopeniaYesNo
Do you take or have you ever taken bisphosphonates or other medications to treat Osteoporosis or bone cancer? (i.e., Fosamax, Actonel, Zometa, Boniva, Reclast, Prolia)YesNo
Joint replacementYesNo

Neurological / Psychiatric

Stroke / TIAYesNo
Seizures or EpilepsyYesNo
Fainting or dizzy spellsYesNo
Other neurologic diseaseYesNo
Depression or anxietyYesNo
Autism or other developmental disabilityYesNo
Dementia / Alzheimers diseaseYesNo
Other psychiatric disordersYesNo

Renal (kidney)

Renal failure / dialysisYesNo
Other kidney diseaseYesNo

Respiratory

Seasonal AllergiesYesNo
AsthmaYesNo
COPD, Chronic bronchitis, or emphysemaYesNo
TuberculosisYesNo
Sleep apnea / excessive snoringYesNo

Vision

GlaucomaYesNo
Wear contact lensesYesNo

Anesthesia

Have you had adverse reactions to general anesthesia?YesNo
Have you had adverse reactions to local anesthesia?YesNo
Recent cold or upper respiratory tract infectionYesNo
Latex allergyYesNo
Egg allergyYesNo
History or family history of malignant hyperthermiaYesNo
Women Only
Are you pregnant or trying to get pregnant?YesNo
Are you breast feeding?YesNo
Do you take birth control pills?YesNo

If you are using oral contraceptives it is important you understand that Antibiotics & other medications may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills after the course of antibiotics or other medication is completed. Please consult with your physician for future guidance.

If you are pregnant, possibly pregnant or trying to become pregnant, surgery anesthetic or other medication may significantly harm the development of your baby, especially during the first trimester. Please advise the doctor if there is any chance of your being pregnant!

Past Surgical History/Hospitalizations

Please list any past surgeries or hospitalizations and dates:

Medications

Please list any medications you are taking (please include over the counter and herbals):

Medication Allergies

Please list any medication allergies and the type of reaction:

Social History
 Smoke cigarettes/cigars 
 Smokeless tobacco 
 Alcohol use   Daily   Weekends/Social   Rare 
 Illicit drug use (i.e., IV drugs, cocaine, marijuana, narcotics)
Other Medical Conditions Not Listed Above

Please list any other medical conditions:

 Is there anything else you would like to discuss privately with the doctor?
Payment Policies

Payment is due at time of service unless alternative arrangements have been made in advance. Return checks that are returned due to "insufficient funds" are subject to a $35.00 service fee.

Minors

The adult accompanying a minor is responsible for payment. This office will not bill a non-custodial parent for services delivered to a minor.

Authorization

I hereby authorize payment directly to Bluhm, Dorsch and Vandervort, P.C. of the group benefit insurance benefits otherwise payable to me. I authorize the use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize Bluhm, Dorsch and Vandervort, P.C. to act as my agent in helping me to obtain payment from my insurance companies. I permit a copy of this authorization to be used in place of the original. I give Bluhm, Dorsch and Vandervort, P.C., its employees, and or other agents express prior consent to contact me at any/all phone numbers, including cell numbers (by phone call or text message) and email addresses, for the purpose of appointments, treatment, insurance, or payment. I confirm that all information on this patient registration is correct to the best of my knowledge.

HIPAA Patient Consent Form
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