Microsoft word - patient information sheet 4 final locked.doc

Patient Information Dale D. Batten, DMD, PA
Comprehensive Dentistry
Thank you for choosing our practice for your dental needs. Please complete this form in ink. If you have any questions or concerns, don’t hesitate to ask for assistance. We will be happy to help. Who may we thank for referring you to us? Name of person responsible for this account Dental Insurance Information Name of Insured Yes IF YES, PLEASE COMPLETE THE FOLLOWING: Dale D. Batten, DMD, PA
Comprehensive Dentistry
How often do you get your teeth cleaned? PLEASE ANSWER YES OR NO TO THE FOLLOWING: Unhappy with the appearance of your teeth Problems with effectiveness or bad reaction to dental anesthetic 10. Part of your mouth is sensitive to temperature 16. Jaw problems (tempromandibular joint) 17. Difficulty opening your mouth widely 19. Awakened with an awareness of your teeth or jaws SUPPLEMENTAL DENTURE HISTORY: If you are wearing removable complete or partial dentures, please complete the following: Has your present denture been relined? When? Is your present denture a problem? Describe: When did you receive your first partial or complete denture? How long have you worn your present denture? Dale D. Batten, DMD, PA
Comprehensive Dentistry
Please list all medications you are currently taking: (Women) Are you pregnant
What is the estimate of your general health? Poor Please check if you have had any of the following: Have you ever taken any of these medications? Biophosphonates/
(for osteoporosis)
Blood Thinners:
Please describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment: To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child ever have a change in health. I certify that if I and/or my dependant(s), have insurance coverage, I assign directly to Dale D. Batten, DMD, PA all insurance benefits, if any, and otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. The above named doctor may use my healthcare information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services or referring doctors offices. In consideration of the services rendered to me by this dental office I am obligated to pay said office in accordance with its credit terms and policies. . I consent to the making of videotapes, photographs and x-rays before during and after treatment, and to the use of same by the doctor in scientific papers, marketing or demonstrations. I certify that I have read or had this read to me the contents of this form and do realize the risks and limitations. Signature:_______________________________Date:_________ (Patient, Parent, Guardian or Personal Representative)

Source: http://www.battendental.com/Documents/PatientInformationSheet.pdf