Insured’s Name: DOB: SS#: Do you have Secondary
Dental Insurance?
Insured’s Employer: Insurance Co.:
Phone Number: Group Number: Local #:
Paent Name:
Name: Address: Telephone:
Paent Registraon
Financial Policy
10435 Illinois Road, Fort Wayne, IN 46814
Ph: (260)469-3671 | www.holmesfamilydenstry.com
Today’s Date:Birth Date:Gender: Age:
Home Address:
Email Address:
City: State: Zip:
Home Phone:
Work Phone:
Person Responsible for Account:
How did you hear about our oce? Reason for Visit:
EMERGENCY INFORMATION (A relave not living with you)
Cell Phone:
Parent if Paent is a Minor:
Your Employer:
Occupaon:
FM
Thank you for choosing our oce as your dental health care provider. We are commied to providing you with the highest quality dental care, so
that you may fully aain opmum oral health. Please understand that payment of your bill is considered part of your treatment. Payment is due at
the me service is provided. We ask that you pay the deducble and co-payment, which is the esmated amount not covered by your insurance
company. Our oce accepts cash, all major credit cards, and outside nancing informaon is available upon request. Please Note: Returned checks
will be subject to addional fees. In the case it becomes necessary for our oce to enlist a collecon service and/or legal assistance, you will be
responsible for any collecon and/or legal charges incurred up to 35%.
Do You Have Insurance?
As a courtesy to you we will help you process all your insurance claims. Please understand that we will provide an insurance esmate to
you, however it is not a guarantee that your insurance will pay exactly as esmated. Your insurance company and your plan benets
ulmately determine the amount paid. We will, of course, do all we can to make sure your esmate is as accurate as possible.
All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider,
our relaonship is with you, our paent, not with your insurance company. Your insurance policy is a contract between you, your
employer, and your insurance company. Our oce is not a party to that contract.
Our pracce is commied to providing the best treatment for our paents and we charge what is usual and customary for our area. You
are responsible for payment regardless of any insurance company’s arbitrary determinaon of usual and customary rates.
We ask that you sign this form and/or any other necessary-documents that may be required by your insurance company. This form
instructs your insurance company to make payment directly to our oce.
Insurance payments are ordinarily received within 30-60 days from the me of ling. If your insurance company has not made payment
within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or
your claim is denied, you will be responsible for paying the full amount at that me.
We will cooperate fully with the regulaons and requests of your insurance company that may assist in the claim being paid. Our oce
will not however, enter into a dispute with your insurance company over any claim.
We thank you for the opportunity to serve your dental health care needs and welcome quesons you may have concerning your care or our
nancial policy.
DENTAL INSURANCE INFORMATION (Primary Carrier)
Yes No
Paent’s Signature (Parent of Child)
I have read, understand and agree to the above terms and condions. I authorize my insurance company to pay my dental benets directly to my dental
oce.
The undersigned, hereby authorizes Doctor to take X-rays, study models, photographs, or any other diagnosc aids deemed appropriate by Doctor
to make a thorough diagnosis of the paent’s dental needs. I also authorize Doctor to perform any and all forms of treatment, medicaon, and
therapy that may be indicated. I also understand the use of anesthec agents embodies a certain risk. I understand that responsibility for payment
for dental Services provided in this oce for myself or my dependents is mine, due and payable at the me services are rendered unless nancial
arrangements have been made. I further understand that a nance, rebilling, collecon charge or aorney fee will be added to any overdue balance.
CONSENT
Date
Social Sec. #:
Please Check One: Single Married Separated Widowed
SUBMIT
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Dental History
10435 Illinois Road, Fort Wayne, IN 46814
Ph: (260)469-3671 | www.holmesfamilydenstry.com
Referred by: How would you rate the condion of your mouth?
Previous Denst:
Date of most recent dental exam:
Date of most recent treatment (other than a cleaning)
Date of most recent x-rays/
/
//
/
/
How long have you been a paent? Months/Years:
Excellent FairGood Poor
PERSONAL HISTORY NO YES
Paent’s Signature:
Doctors Signature:
Date:
Date:
1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) ________
2. Have you had an unfavorable dental experience?
3. Have you ever had complicaons from past dental treatment?
4. Have you ever had trouble geng numb or had any reacons to local anesthec?
5. Did you ever have braces, orthodonc treatment or had your bite adjusted?
6. Have you had any teeth removed or missing teeth that never developed?
Gum AND bONE
7. Do your gums bleed or are they painful when brushing or ossing?
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
9. Have you ever noced an unpleasant taste or odor in your mouth?
10. Is there anyone with a history of periodontal disease in your family?
11. Have you ever experienced gum recession?
12. Have you ever had any teeth become loose on their own (without an injury), or do you have diculty eang an apple?
13. Have you experienced a burning or painful sensaon in your mouth not related to your teeth?
TOOTH STRucTuRE
14. Have you had any cavies within the past 3 years?
15. Does the amount of saliva in your mouth seem too lile or do you have diculty swallowing any food?
16. Do you feel or noce any holes (i.e. ping, craters) on the bing surface of your teeth?
17. Are any teeth sensive to hot, cold, bing, sweets, or avoid brushing any part of your mouth?
18. Do you have grooves or notches on your teeth near the gum line?
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked lling?
20. Do you frequently get food caught between any teeth?
bITE AND jAw jOINT
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together?
23. Do you avoid or have diculty chewing gum, carrots, nuts, bagels, baguees, protein bars, or other hard, dry foods?
24. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
25. Are your teeth becoming more crooked, crowded, or overlapped?
26. Are your teeth developing spaces or becoming more loose?
27. Do you have more than one bite, squeeze, or shi your jaw to make your teeth t together?
28. Do you place your tongue between your teeth or close your teeth against your tongue?
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
30. Do you clench your teeth in the dayme or make them sore?
31. Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth?
32. Do you wear or have you ever worn a bite appliance?
SmILE cHARAcTERISTIcS
33. Is there anything about the appearance of your teeth that you would like to change?
34. Have you ever whitened (bleached) your teeth?
35. Have you felt uncomfortable or self conscious about the appearance of your teeth?
36. Have you been disappointed with the appearance of previous dental work?
I rounely see my denst every:
wHAT IS YOuR ImmEDIATE cONcERN?
3 mo. 6 mo.4 mo. 12 mo. Not rounely
SUBMIT
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signature
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DRUG PURPOSE DRUG PURPOSE
1. hospitalizaon for illness or injury
2. an allergic reacon to:
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthec
uoride
metals (nickel, gold, silver, ____________)
latex
other
3. heart problems, or cardiac stent within the last six months
4. history of infecve endocardis
5. arcial heart valve, repaired heart defect
6. pacemaker or implantable debrillator
7. orthopedic implant (joint replacement)
8. rheumac or scarlet fever
9. high blood pressure
10. a stroke
11. anemia or other blood disorder
12. prolonged bleeding due to a slight cut (INR > 3.5)
13. emphysema, shortness of breath, sarcoidosis
14. tuberculosis, measles, chicken pox
15. asthma
16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deciency
21. hormone deciency
22. high cholesterol or taking stan drugs
23. diabetes (HbA1c =_______)
24. stomach or duodenal ulcer
25. digesve disorders (i.e. celiac disease, gastric reux)
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. arthris
28. autoimmune disease
(i.e. rheumatoid arthris, lupus, scleroderma)
29. glaucoma
30. head or neck injuries
31. epilepsy, convulsions (seizures)
32. neurologic disorders (ADD/ADHD, prion disease)
33. viral infecons and cold sores
34. any lumps or swelling in the mouth
35. hives, skin rash, hay fever
36. sexually tranismied disease, HIV, or HPV
37. hepas (type _______)
38. HIV / AIDS
39. tumor, abnormal growth
40. radiaon therapy
41. chemotherapy, immunosuppressive medicaon
42. psychiatric treatment
43. andepressant medicaon
44. alcohol / recreaonal drug use
ARE YOU:
45. presently being treated for any other illness
46. aware of a change in your health in the last 24 hours
(i.e. fever, chills, new cough, or diarrhea)
47. taking medicaon for weight management
48. taking dietary supplements
49. oen exhausted or fagued
50. experiencing frequent headaches
51. a smoker, smoked previously or use smokeless tobacco
52. oen unhappy or depressed
53. currently pregnant
Paent Name:
Medical History
10435 Illinois Road, Fort Wayne, IN 46814
Ph: (260)469-3671 | www.holmesfamilydenstry.com
Nickname: Age:
Name of Physician/and their specialty:
Most recent physical examinaon:
What is your esmate of your general health?
Purpose:
Excellent FairGood Poor
DO YOU HAVE or HAVE YOU EVER HAD: NO NOYES YES
Describe any current medical treatment, impending surgery, genec/development delay, or other treatment that may possibly aect your dental
treatment. (i.e. Botox, Collagen Injecons)
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Paent’s Signature:
Doctors Signature:
Date:
Date:
LIST ALL MEDICATIONS, SUPPLEMENTS, AND OR VITAMINS TAKEN WITHIN THE LAST TWO YEARS.
SUBMIT
Purpose: This form is used to obtain acknowledgement of receipt of our Noce of Privacy Pracces or to docu-
ment our good faith eort to obtain that acknowledgement.
Purpose: This form is used to obtain authorizaon to release informaon regarding yourself covered under the
Privacy Act to people other than yourself.
**You may refuse to sign the acknowledgement**
10435 Illinois Road, Fort Wayne, IN 46814
Ph: (260)469-3671 | www.holmesfamilydenstry.com
I,
I,
Please print name:
Please print name:
Please print name:
Please print name:
We aempted to obtain acknowledgement of receipt of our Noce of Privacy Pracces, but acknowledgement
could not be obtained because:
Individual refused to sign
Communicaon barriers prohibited obtaining the acknowledgement
Other
Relaonship:
Relaonship:
Relaonship:
**For Oce Use Only**
Signature: Date:
, have received a copy of this oce’s Noce of Privacy Policies.
, authorize the following person(s) to have access to
informaon covered under the Privacy Pracce regarding myself.
Authorizaon to Release Informaon
Authorizaon of Receipt of Noce of Privacy Pracces
SUBMIT
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