Medical History

PATIENT INFORMATION

A Parent Or Guardian Must Be Present At All Dental Appointments For Minors
Name

First NameLast Name
Gender:

Other
Status:

Other
Birth Date:

MonthDayYear
Soc. Sec#
Dr. License #
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Patient Employer
Emergency Contact
Emergency Contact #
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about our office? (I.e. Insurance company, Google, Friend, Postcard, Other)
- Missed appointments WITHOUT a 24 hour notice will result in a $30.00 no show fee per every half hour scheduled.
RESPONSIBLE PARTY

A Parent Or Guardian Must Be Present At All Dental Appointments For Minors
Responsible for account
Relation to patient
Birth Date:

MonthDayYear
Soc. Sec#
Dr. License #
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party Employer
-Missed appointments WITHOUT a 24 hour notice will result in a $30.00 no show fee per every half hour scheduled.
DENTAL INSURANCE INFORMATION
Dental Insurance Provider
Ins Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Address

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber ID #
Group #
Subscriber Name
Birth date

MonthDayYear
Date
Soc. Sec #
Employer
Subscriber relationship to patient
-Missed appointments WITHOUT a 24 hour notice will result in a $30.00 no show fee per every half hour scheduled.
SECONDARY DENTAL INSURANCE INFORMATION
Dental Insurance Provider
Ins Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Address

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber ID #
Group #
Subscriber Name
Birth date

MonthDayYear
Date
Soc. Sec #
Employer
Subscriber relationship to patient
A PARENT OR GUARDIAN MUST BE PRESENT AT ALL DENTAL APPOINTMENTS FOR MINORS
MEDICAL HISTORY
Current Physician
Office Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Exam

MonthDayYear
Date
Preferred Pharmacy
Pharmacy Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Address

Street Address

Street Address Line 2

CityState

Zip Code
Allergies :
Other Allergies:
Current Medications :
Please check all that apply :
Type
CONSENT TO PROCEED WITH TREATMENT
I authorize NORTH SALT LAKE DENTAL and/or such associates or assistants as they may designate to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any individual for which I have responsibility, including administration of any sedative (including nitrous oxide), analgesic, therapeutic and pharmaceutical agents, including those related to restorative, palliative, therapeutic or surgical treatments.

I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to, bruising hematoma, cardiac stimulation, and temporary numbness and muscle soreness.

I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may associated with general preventative and operative treatments procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of all foregoing procedures have been explained to me; if necessary, I have been given the opportunity to ask questions.
FINANCIAL POLICY
- I understand that NORTH SALT LAKE DENTAL will bill my insurance company as a courtesy, but that the amount incurred is ultimately my responsibility, should my insurance company not pay. I also understand that it is my responsibility to direct all inquires regarding unpaid claims to my insurance company and to contact them myself.
- Missed appointments WITHOUT a 24 hour notice will result in a $30.00 no show fee per every half hour scheduled. Leaving a voicemail is not considered a canceled appointment.
- Payment is due at the time of service unless prior arrangements have been made (i.e. insurance, Care Credit)
- I agree to pay all costs and attorney fees if a suit or collection agency is instituted hereunder to collect money owed by me. 40% of my balance will be added to the overall balance if a collection agency is used.
- I grant my permission to you or your assignee to telephone me at my home or work place to discuss matters related to this form.
- I authorize assignment or payment of all dental benefits to which I or other family members are entitled, including private or group dental benefits otherwise payable to the undersigned, to NORTH SALT LAKE DENTAL.
A PARENT OR GUARDIAN MUST BE PRESENT AT ALL DENTAL APPOINTMENTS FOR MINORS
Signature

Clear
Date

MonthDayYear
Date
Relationship to Patient
Should be Empty:

PATIENT INFORMATION

RESPONSIBLE PARTY

DENTAL INSURANCE INFORMATION

SECONDARY DENTAL INSURANCE INFORMATION

CONSENT TO PROCEED WITH TREATMENT

FINANCIAL POLICY