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(770) 475-7551
3005 Old Alabama Road, Suite 320 Alpharetta, GA 30022
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New Patient Forms
Patient Full Name
*
Preferred Name
Date
*
Marital Status
Single
Married
Separated
Divorced
Widowed
Address
*
Home Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Telephone (Home)
*
(Office)
(Cell)
*
SSN
Email
*
How Did You Hear About Us? If Referred, by Whom?
Is Another Member of Your Family or a Relative in Our Practice
Yes
No
Name
Relationship
Emergency
Who Would You Like Us to Contact FIRST in Case of an Emergency?
*
Relationship to Patient
Address
Home Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Telephone (Home)
(Office)
(Cell)
Financial
Who is Financially Responsible for the Payment of Your Account?
*
Relationship to Patient
Phone Number, if Different fromPatient
Address
Home Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
PAYMENT IN FULL IS DUE AT THE TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED. We will submit your insurance claim for you. However, we do not accept assignment.
Insurance Information
Insurance Co. Name
Group #
Insurance Co. Customer Service Phone
Insurance Co. Address
Home Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Subscriber's Name
Relation
Subscriber's Date of Birth
Subscriber's SSN
Subscriber's Employer
The information that I have given is true and correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence. I hereby authorize the doctor or designated staff to take x-rays, study models, bacteriological cultures, diagnostic casts, photographs, biopsies of oral tissue, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the above name patient’s dental needs. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I consent to the use of appropriate medication and therapy as deemed necessary. I fully understand that using anesthetic agents embodies a certain risk. I understand that I am responsible for the total fee for the services rendered.
Patient/Parent/Guardian Signature
*
Date
*
PATIENT HEALTH HISTORY
Recent research indicates a strong relationship between the mouth and body. We are going to be asking you some questions about your family history and your overall health that we may not have asked you about before.
Name
*
Telephone (Home)
*
(Office)
(Cell)
*
Email
*
Are You Under the Care of Physician?
Yes
No
Primary Care Physician
Have You Had Any Serious Illnesses or Operations in the Last 5 Years?
Yes
No
Describe
Have You Ever Had a Blood Transfusion?
Yes
No
If yes, When?
Are You on a Blood Thinner?
Yes
No
Are You Pregnant?
Yes
No
Are You Nursing?
Yes
No
Are You Taking birth controls pills?
Yes
No
Check if You Currently Have or Have a History of the Following:
Artificial Hip or Knee Joint
Heart Murmur
Rheumatic Fever
Diabetes
Hepatitis
Alcohol Abuse
Congenital Heart Disease
Kidney Disease/Stones
Drug Abuse
COPD
Mitral Valve Prolapse
Anemia
Nervous/Anxious
Pacemaker
Arthritis
Epilepsy/Seizures
Sinus
Artificial Heart Valve
Glaucoma
Stroke
Asthma
Heart Attack/Cardiac Issues
Thyroid
Bruise Easily
HIGH/LOW blood pressure
Tuberculosis
Cancer
HIV/AIDS
Ulcers
Chemotherapy/Radiation
Hypoglycemia
Venereal Disease
Artificial Hip or Knee Joint, If Yes, Premed?
Yes
No
Heart Murmur, If Yes, Premed?
Yes
No
Rheumatic Fever, If Yes, Premed?
Yes
No
Other
Check if You Are Allergic To or Have Reacted Adversely to Any of the Following:
Aspirin
Codeine/Other Narcotics
Latex
Barbiturates (Sleeping Pills)
Iodine
Local Anesthetics
Antibiotics:
Penicillin
Erythromycin
Sulfa
Tetracycline
Other
Check if You are Having Problems with Any of the Following:
Bleeding Gums
Grinding Teeth
Sensitivity to Hot or Cold
Clicking or Popping Jaw
Sensitivity When Chewing
Dry Mouth
Mouth Breathing
Sores or Growths in Your Mouth
Gum disease has been linked with an increased risk for many chronic diseases. Eliminating gum disease is especially important to the oral and overall health.
Tobacco User
Tobacco users are more likely to develop gum disease which is more severe and more difficult to eradicate. Gum disease itself has recently been linked with an increased risk for heart disease. Since tobacco users are already at an increased risk for heart disease, and gum disease only worsens the risk, it is vitally important for tobacco users to do whatever is necessary to eliminate gum disease.
Current Tobacco User?
Yes
No
What Form (Cig, Pipe, Chew, etc.)
Previous Tobacco User?
Yes
No
When Did You Quit?
Diabetes
Diabetes is well –known risk factor for gum disease. Research is confirming that when left untreated gum disease makes it harder for you to control your blood sugar. Elimination of gum disease can improve your blood sugar control reducing your risk for the serious complications.
How is your diabetes control?
Good
Fair
Poor
Family History of Gum Disease
Some people are genetically prone to developing gum disease even if they take excellent care of their mouths.
Do you have any family history of gum disease?
Yes
No
Don't Know
Stress
Stress is a well-known risk factor for gum disease. Is your stress level too high?
Yes
No
Rheumatoid Arthritis
There is a bi-directional connection between rheumatoid arthritis. If you have arthritis you are at an increased risk for gum disease. Emerging research suggests that eliminating any gum disease and then keeping it at bay can lessen the crippling effects of arthritis.
Medication
Purpose
Dose
How Long?
Other Comments
The information that I have given is true and correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence. I hereby authorize the doctor or designated staff to take x-rays, study models, bacteriological cultures, diagnostic casts, photographs, biopsies of oral tissue, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the above name patient’s dental needs. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I consent to the use of appropriate medication and therapy as deemed necessary. I fully understand that using anesthetic agents embodies a certain risk. I understand that I am responsible for the total fee for the services rendered.
Patient/Parent/Guardian Signature
*
Date
*
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