Patient Information Form - Lakeside Dental

Patient Information

Today's Date

Patient's Name

First Last

Preferred Name

Are you are filling out this form for another person

Yes

Your Name

Relation

Date of Birth

Age

Sex

Male
Female

Address

Street Address Address Line 2 City State ZIP Code

Phone (home)

Phone (work)

Phone (cell)

Email

Employer/School:

Occupation:

Spouse’s Name:

Employer's Address

Street Address Address Line 2 City State ZIP Code

DENTAL INSURANCE:

Yes
No

Subscriber's Name

SS#

DOB:

Relation

Emergency contact name

Emergency contact relation

Emergency contact phone #

Were you referred to our office? By Whom?

Dental Oral Health

Are you currently in pain?

Yes
No

Please indicate any of the following concerns and any previously treated dental conditions:

Describe concern

What are your teeth sensitive to?

Air
Cold
Hot
Biting

What is the primary reason for your visit today?

Describe any special areas of concern you would like to have addressed by Dr. Bushnell and his staff:

Do you have any apprehension regarding your visit?

Fear
Time
Money
Tension

Do you prefer Nitrous Oxide at dental visits?

Yes
No

Your current dental health is:

Good
Fair
Poor

When was your last dental visit?

How often do you have dental exams?

When do you usually brush?

What products do you use for dental care?

Are you happy with how your smile looks?

Yes
No

If not, what would you like to change?

Medical History

Are you allergic to - or have you had a bad reaction to - any of the following?

Foods allergic to:

Other Allergies

Please list any medications you are taking: (Or provide a complete list to the receptionist).

Do these include:

Blood Thinners
Osteoporosis meds (Bisphosphonate)
Insulin
Pain Med
Sedatives

OTC (over-the-counter) meds:

Vitamins/Supplements:

Do you have a preferred pharmacy?

Your current health is:

Good
Fair
Poor

Do you smoke or use tobacco?

Yes
No

Have you abused drugs in the past?

Yes
No

Are you pregnant?

Yes
No

Week #

Are you nursing?

Yes
No

Do you require antibiotics before dental treatment?

Yes
No

Do you have a personal physician?

Yes
No

If so, Physician’s Name:

Phone:

Reason of last visit:

Have you ever had any of the following diseases or medical problems? (Check all that apply)

Hepatitis type:

Diabetes type:

Have you ever experienced prolonged or excessive bleeding?

Yes
No

Please list any other serious medical condition:

Is there ANY other information you would like us to be aware of?

Consent

CONSENT – To the best of my knowledge, all of the preceding information is correct. If there is ever any change to this medical status, this practice will be informed without fail. I understand this information will be held in the strictest confidence and will not be shared with anyone outside the office without written consent that is signed and dated. I do authorize the release of all information necessary to secure the payment of benefits. I hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual. I also authorize the use of anesthesia and/or other medication necessary for dental treatment to be rendered by the dental staff.

Signature

First Last

Date

150 BILLS ROAD LAKESIDE, MT 59922 (406) 844-3825