Glensfallsdentist.com

PATIENT’S NAME ____________________________ DATE TODAY___________
HOME ADDRESS______________________________________________________________________
CITY/STATE/ZIP _____________________________________________________________________
Home Phone #_________________________Work Phone #______________________
Social Security # _______-_____-_______ Date of Birth _____/______/__________
Patient’s Employer ____________________________________________________________________
Patient’s Marital Status ___________
Name of Spouse ___________________________________

How will you pay for treatment? Cash ___ Check ___ Credit Card ____ Ins. & Co-payment ___
Primary Dental Insurance:

Employer/Company _________________________________Phone #____________________
Insurance Co. ______________________________________Phone#_____________________
Group/Policy #_______________________________________________________________

Subscriber’s name ____________________________________Birth date___/____/____
Subscriber’s Soc. Sec. # (if different from above)_____-___-______
Relationship of patient to subscriber __________

Secondary Dental Insurance (if any):

Employer/ Company _________________________Phone#_____________________________
Insurance Co.________________________________ Phone #___________________________
Group/Policy # _________________________________________________________________
Subscriber’s name ___________________________________ Birth date ___/___/____
Subscriber’s Soc. Sec. # _____-____-_______ Relationship of patient to subscriber _________

 Please note that we expect payment on the day of service.
 If you have dental insurance, we will submit it for you, as long as you bring appropriate insurance claim
information; we expect the appropriate co-payment at the day of service.
 We participate with MOST Empire Blue Cross, Delta Dental, Blue Shield of N.E. New
York, and Teamsters dental plans and we are required to use their appropriate fee schedules with
their required co-payments schedules.
 We will endeavor to make the best ‘guess-timate’ of your insurance coverage for a given visit, BUT as
insurance plan deductibles, maximums, fee schedules, and co-payments are VERY individual, we can
only estimate benefits.
 If there is a balance after the insurance payments have been made, a prompt payment is expected.
 A $35.00 charge will be applied for any missed appointments with out 24 hour notice.
Signature of Patient or Guardian____________________________________________________
How were you referred to our office? ______________________Reason for first visit______________
Physician’s Name_________________________________ Office Phone # ________________________
Are you under any medical treatment now? ________________________________________________
Name & Location of Preferred Pharmacy ______________________________________________
Please circle any of the following that you may have an allergy to (besides cats and dust):
Penicillin or Amoxicillin
Sulfa Drugs Latex
Keflex or Ceclor
Tetracycline
Novacaines
Erythromycin
Any Meds not listed? _____________________
Please circle any of the following which you have had or have now:
Anemia Epilepsy
Jaundice Shingles
Ankle swelling Glaucoma Kidney ailment Shortness of breath
Arthritis Heart murmur Liver ailment Sinus Trouble
Artificial joint Heart trouble Low blood pressure Stroke
Artificial valve Hepatitis MRSA Thyroid Problems
Asthma Herpes Osteoporosis Tuberculosis
Cancer Pacemaker
Celiac Disease High blood pressure Psychiatric treatment
Congenital heart lesion HPV Rheumatic Fever
Diabetes HIV /AIDS Scarlet Fever

Are you presently taking Bisphosphonates(Fosamax)? YES or NO
Please list any medications you are taking (please list):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Have you had any surgeries, if so please list?
______________________________________________________________________________________
______________________________________________________________________________________
Do you smoke? ________________ Do you drink alcohol? ___________How Much______________
Do you chew tobacco? __________ Do you take illegal substances? _______
Have you ever had a blood test for hepatitis or Aids?__________
Have you received hepatitis vaccinations?___________________

Have you ever had or been recommended to have

Antibiotic Pre-medication for dental work? ____________
If female, are you pregnant? ______ If yes, who is your OB-GYN? ____________________
Any concerns in your mouth?_____________________________________________________________
Up Date Health History X______________________________________date______________________
X______________________________________date______________________
X______________________________________date______________________

Source: http://www.glensfallsdentist.com/files/68543391.pdf