425-258-2633
4608 Dogwood Drive, Suite A
Everett, WA 98203

Patient Form


Patient Name: Title: Mr.   Ms.  Mrs. Last: First: MI:
Prefer to be called: Gender:Male    Female
Birthdate:// Age: Social Security #:
Single     Married    Widowed    Divorced    Separated
Home Address: Street:
City: State: Zip:
Home Phone:() Pager/Cell Phone:() Work Phone:()  Ext.

Best time to reach you:
Referred by:


Other family members seen by us:

Email: Employer:
How long at current job? Occupation:
Employer Address:
Spouse/Parents Name: If a child, lives with:Mother  Father  Other

Nearest Relative Not Living With You

His/Her Name: Relation
Home Phone:() Work Phone:()

Dental Insurance

Primary Insurance Company: Insurance Company Name:
Phone:() Group Number (Plan, Local or Policy #):
Insurance Company Address Street:
City: State: Zip:
Insured’s Name: Patient ID#:
Birthdate:// Relation:
Insured’s Employer: Employer Address:
Secondary Insurance Company: Insurance Company Name:
Phone:() Group Number (Plan, Local or Policy #):
Insurance Company Address Street:
City: State: Zip:
Insured’s Name: Patient ID#:
Birthdate:// Relation:
Insured’s Employer: Employer Address:
In order to keep our fees reasonable and to best serve the needs of all patients, we request a minimum of 48 hours notice to change a scheduled appointment. In the event that less advanced notice is given or if a patient fails to show for a scheduled appointment a $75.00 fee will be assessed. Please note that this fee is not covered by dental insurance and payment is the patient’s responsibility. By signing below I acknowledge that I have read and understand this policy.
Signature: Date:

Dental History

Why have you come to the dentist today?
Do you currently have pain or swelling? Yes   No
Do you desire complete dental care? Yes   No
Are your teeth sensitive to heat, cold or sweets? Yes   No
Do you have difficulty chewing food? Yes   No
Do you grind or clench your teeth? Yes   No
Do your gums ever bleed? Yes   No
Have you ever had Periodontal disease? Yes   No
Have you ever noticed slow healing sores in or around your mouth? Yes   No
What is your main source of drinking water? (Well, City, Other)
Are you worried about receiving dental treatment? Yes   No
During dental treatment would you prefer to use laughing gas (nitrous oxide)? Yes   No
During dental treatment would you prefer to use headphones? Yes   No
Do you still have your wisdom teeth? Yes   No
Do you gag easily? Yes   No
How is your current dental health? Good   Fair   Poor
Name of Previous/Present Dentist:
City:
Date of last visit:
When was your last dental cleaning?
Last Dental x-rays?
Are you happy with the color of your teeth? Yes   No
Are you happy with the way your smile looks? Yes   No
If not, what would you change?

Medical History

Do you have a personal physician? Yes   No
Physician’s Name:
Phone: ()
Date of last visit:
Your current physical health is: Good   Fair   Poor
Are you currently receiving treatment by a physician? Yes   No
Please explain:
Do you smoke or use tobacco? Yes   No
For Women: Are you currently taking birth control pills? Yes   No
Are you currently pregnant? Yes   No   Unsure
Week #:
Nursing: Yes   No
Do you have or have you experienced any of the following?
Abnormal bleeding: Yes   No Alcohol Abuse: Yes   No Anemia: Yes   No
Arthritis: Yes   No Artificial Bones/Joints: Yes   No Artificial Valves: Yes   No
Asthma: Yes   No Blood Transfusion: Yes   No Cancer: Yes   No
Chemotherapy: Yes   No Chicken Pox: Yes   No Colitis: Yes   No
Congenital Heart Defect: Yes   No Diabetes: Yes   No Difficulty Breathing: Yes   No
Drug Abuse: Yes   No Emphysema: Yes   No Epilepsy: Yes   No
Ever Hospitalized: Yes   No Fainting Spells: Yes   No Fever Blisters: Yes   No
Glaucoma: Yes   No Hay Fever: Yes   No Headaches: Yes   No
Heart Attack: Yes   No Heart Murmur: Yes   No Heart Surgery: Yes   No
Hemophilia: Yes   No Hepatitis: Yes   No Herpes: Yes   No
High Blood Pressure: Yes   No HIV+ / AIDS: Yes   No Kidney Problems: Yes   No
Liver Disease: Yes   No Low Blood Pressure: Yes   No Lupus: Yes   No
Mitral Valve Prolapse: Yes   No PaceMaker: Yes   No Persistent Cough: Yes   No
Psychiatric Problems: Yes   No Radiation Treatment: Yes   No Rheumatic Fever: Yes   No
Scarlet Fever: Yes   No Seizures: Yes   No Shingles: Yes   No
Sickle Cell Disease: Yes   No Sinus Problems: Yes   No Steroid Therapy: Yes   No
Stroke: Yes   No Thyroid Problem: Yes   No Tonsilitis: Yes   No
Tuberculosis (TB): Yes   No Ulcers: Yes   No Venereal Disease: Yes   No
Sleep Apnea Yes   No
Please list any serious medical condition(s) that you have experienced
Are you taking any prescription drugs or over the counter drugs such as aspirin? If yes please list each one:
Are you allergic to any of the following?
Aspirin: Yes   No Barbiturates: Yes   No Codeine: Yes   No
Dental Anesthetics: Yes   No Erythromycin: Yes   No Jewelry / Metals: Yes   No
Latex: Yes   No Penicillin: Yes   No Sedatives: Yes   No
Sulfa Drugs: Yes   No Tetracycline: Yes   No Other: Yes   No
Please list anything additional that causes allergic reactions:
Do you require antibiotics before dental treatment? Yes   No
Do you have clicking or popping in your jaw joint? Yes   No
Do you ever have pain or soreness in front of your ears? Yes   No
Do you ever have ear pain? Yes   No
Do you wake up with your jaw sore or tired? Yes   No
Do you ever have difficulty opening widely? Yes   No
Do you get headaches? How often?
Does anything trigger your headaches? Yes   No
To what degree would you say your headaches affect your life?
Have you been treated or evaluated for your headaches? Yes   No
Do you snore? Yes   No
Do you have high blood pressure? Yes   No
Has anyone reported that you choke or gasp for air while sleeping? Yes   No
Are you excessively tired during the day? Yes   No
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease? Yes   No
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous biphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastic cancer? Yes   No

Authorization

I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1-1/2% finance charge (18% APR) may be added to my account, in addition to any collection charges.

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/ medical histories and other information about my dental treatment to third party payors and/or other health professionals.

Signature: Date:
  Adult Patient   Father/Husband   Mother/Wife   Guardian