Welcome

Welcome to True Dental Group

Patient Name

How do you prefer to be addressed?

Mailing Address

City State Zip

Birth Date

Age

Sex

   Male
   Female

Marital Status

  Single
  Married
  Widow
  Separated
  Divorced

Cell Phone   Home Phone

Occupation Employer

Time with  current Employer Work Phone

Business Address City State Zip

Driver License Number
Social Security Number 

Email Address

 

Responsible Party Information (if different from patient)

 

Name Relationship to patient

Mailing Address

City State   Zip

Birth date Age
Sex

Male

Female

Cell Phone Home Phone

Occupation Employer

Time with current employer   Work Phone

Business Address City State Zip

Do you give permission to any other person to give consent for treatment: Yes or No Who can consent for treatment

 

Person to Contact in Case of Emergency

Name   Phone

 

Staying Connected

True Dental Group has installed integrated telephone technology, merging our office software with our phone system. We now have the ability to both receive and send out text messages to our patients. What is the best cell phone number for you?

Contact Phone

Please circle yes or no below

  Yes: I authorize True Dental Group to communicate with me by text message.

  No: Please do not send me text messages

What is the best email address for you?

 

Please circle yes or no below

  Yes: I authorize True Dental Group to communicate with me by email.

  No: Please do not send me emails

You can reach us online at: Thetruedentalgroup.com and Truesleepkc.com

You can also email us at: Truedentalgroup@gmail.com

 

Acknowledgement of Receipt of Notice of Privacy Policy

*you may refuse to sign this acknowledgement*

I have received a copy of this office’s Notice of Privacy Practices.

Legal Name Date

Office Use Only: Reason for Refusal to Sign

 

Authorization to Release Information

I hereby authorize this facility to release my protected health information to:

Name Phone Number
Name Phone Number
Name Phone Number

 

Insurance Information

Dental Insurance: Primary Policy

Insurance name

Address

Policy Holder Name Relationship to Patient

Policy Holder Social Security Number Member ID

Group Number Policy Holder Date of Birth

Name of Employer Employer Address

 

Dental Insurance: Secondary

Policy Insurance name

Address

Policy Holder Name Relationship to Patient

Policy Holder Social Security Number Member ID

Group Number Policy Holder Date of Birth

Name of Employer   Employer Address

Medical Insurance: Sometimes we can submit claims for dental procedures to your medical insurance to help maximize all of your benefits.

Insurance name

Address

Policy Holder Name Relationship to Patient 

Policy Holder Social Security Number Member ID

Group Number Policy Holder Date of Birth 

Name of Employer Employer Address

Dental History

What brings you to our office today?
When was the last time you were seen by a dentist?
Are you suffering from any oral pain or discomfort?

  Yes 
  No

Do you like the way your smile looks?

  Yes 
  No

Have you ever wanted to have whiter teeth?

  Yes 
  No

Do your gums bleed when you brush or floss?

   Yes
  No

Have you ever been told that you have gum disease?

  Yes
  No

Do you still have your wisdom teeth?

  Yes
  No

Are you missing any teeth?

  Yes
  No

Do you grind or clench your teeth at night or during the day?

  Yes
  No

Do you feel nervous about receiving dental treatment?

  Yes
  No

Have you ever had Nitrous Oxide (Laughing Gas) for dental treatment?

  Yes
  No

Consent

As the undersigned, I hereby authorize the Doctor to, after thorough explanation, take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make diagnosis of my dental needs. I also authorize the doctor to perform any and all forms of treatment, medication, and therapy that may be indicated (after they are discussed with me) and further authorize and consent the Doctor to choose and employ such assistance as he deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself and my dependents is mine, due payable at the time services are rendered.
All proceeds of insurance are assigned to the doctor when applicable, but without the doctor assuming responsibility for the collection of those claims. If the insurance does not pay my claim within 60 days after it is mailed, it is understood that I will pay the balance of my account and that I will contract my insurance company regarding settlement. It is agreed that payment will not be delayed or withheld because of pending insurance coverage.

If I do not pay the entire balance, or if insurance is unpaid after 60 days, a billing charge will be added to my account. The billing charge will be a periodic rate of 1.5% per month (or a minimum charge of $5.00 for a balance under $100) which is an annual percentage rate of 18%. In case of default of payment, I agree to pay any and all costs in collecting this account, including but not limited to attorney fees and court costs. I understand that, where appropriate, credit reports may be obtained.

Signature of Patient (Guardian)   Date

 

Medical History

Name of your Primary Medical Doctor

Phone Number of your Primary Medical Doctor

Name of your Specialty Doctor (i.e. cardiologist)

Phone Number of Specialty Doctor

Last time you were seen by a medical Doctor 

Have you had any ER visits or hospitalizations within the last year?

 Yes 
  No

If yes, please describe 

Do you smoke?

 Yes
 No

Do you use smokeless tobacco?

  Yes 
 No

Women: Are you Pregnant, or think you might be?

  Yes 
 No

If Yes, when is your due date?

Medications/Drug Allergies

Please circle any medication listed below that you are allergic to, or have had a bad reaction to:


Aspirin

Iodine

Vicodin

Hydrocodone

Oxycodone

Codeine

Tylenol

Ibuprofen

Tramadol

Penicilin

Amoxicillin

Erythromoycin

Keflex

Z-Pack

Lidocaine

Tetracycline

Clydamycin

Sulfa

Nitrous Oxide

Latex

 

Please list all medications you take on a regular basis:

Please list any medication you have taken in the last six months that you do not take on a regular basis:

 

Please circle the medical conditions that apply to you: 

 


High Blood Pressure

Aids

Hemophilia

Diabetes

Alcoholism

Hepatitis

Heart Attack

Anemia

HIV

Stroke

Angina

Hives

Joint Replacement

Asthma

Hyper Activity

Osteoporosis

Birth Control

Hypoglycemia

Congenital Heart Defect

Low Blood Pressure

Jaundice

Blood Thinners

Bruise Easy

Kidney Disease

Epilepsy/Seizures

Deaf

Liver Disease

Drug Dependency

Drug Dependency

Mitral Valve Prolapse

Chronic Pain Therapy

Eating Disorder

Night Sweats

Cancer

Emphysema

Paralysis

Chemotherapy

Fainting Dizzy Spells

Psychiatric Treatment

Radiation Therapy

Cold Sores

Rheumatic Fever

Obstructive Sleep Apnea

Gag Easy

Sickle Cell Disease

Cpap Machine

Glaucoma

Sinus Problems

Gerd/Acid Reflux

Headaches-frequent

STDs

ADHD

Hives

Tuberculosis

 

Please list any other serious illness or medical condition not listed above:

 

Jaw and Airway Assessment

Clicking of the jaw joints

  Yes
 No

Pain in or around the ears

  Yes
 No

Difficulty opening or closing the mouth

  Yes
 No

Difficulty chewing Yes No History of trauma to the jaw

  Yes
 No

Do you snore loudly

  Yes
  No

Do you grind/clench your teeth

  Yes
  No

Do you feel tired or fatigued during the day

   Yes
 No

Have you ever been diagnosed with TMJ/TMD

  Yes
 No

Have you ever had your Airway Measured

  Yes
  No

How did you hear about our office?

Was our office easy to find?

Did you have any trouble finding a parking spot?

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