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Clovis Family Dentistry


The benefits of a happy, healthy smile are immeasurable!
Our goal is to help you reach and maintain optimal oral health.

Please supply us with as much information as possible.
The better we communicate, the better we can care for you.

1. ABOUT YOU

Personal Information
Email Address *
Last Name *
First Name *
Middle Initial
Title
I prefer to be called
Sex *
Birthdate *
Social Security Number *
Driver's License Number
Marital Status
Home Address
Address *
Apartment
Condo
City *
State *
Zip *
Telephone
Cell *
Home
Work
Extension
Direct Line
Employer
Name
Address
City
State
Zip
How long there?
Occupation
Other
Where & when are best times to reach you?
Whom may we thank for referring you?
Other family members seen by us
Name of Previous Dentist
Person Responsible for Account

2. SPOUSE INFORMATION

Personal Information
Name
Employer
Social Security Number
Birthdate
Telephone
Work
Extension
Direct Line
Emergency Contact
Name
Relation
Work Phone Number
Home Phone Number

3. INSURANCE

Dental Coverage
Insurance Company
Company Name
Address
City
State
Zip
Phone Number
Insured Party
Group, Plan, Local or Policy Number
Name
Relation
Birthdate
Social Security Number
Employer Name
Employer Address
Employer City
Employer State
Employer Zip

4. MEDICAL HISTORY

Physician
Do you have a personal physician?
Name
Phone Number
Last Visit Date
Physical Health
Your current physical health
Are you currently under the care of a physician?
Please explain

Do you smoke or use tobacco in any other form?
Have you had any metal rods, pins or implants?
Are you taking prescription / over-the-counter drugs?
Please list each one

Have you ever taken Phen-Fen?(also known as Redux or Pandimin)
If so, when?

Have you taken or do you take Bisphosphonates now (e.g. Aredia, Actonel, Boniva, Fosamax, Zometa)
For Women: Are you using a prescribed method of birth control?
Are you pregnant?
Number of weeks

Are you nursing?
Medical Problems

Have you ever had any of the following diseases or
medical problems

Abnormal Bleeding / Hemophilia
AIDS
Alcohol / Drug Abuse
Anemia
Arthritis
Artificial Bones / Joints / Valves
Asthma
Blood Transfusion
Cancer / Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack / Heart Surgery
Heart Murmur
Hepatitis
Herpes / Fever Blisters
High Blood Pressure
HIV +
Hospitalized for Any Reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prelapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic / Scarlet Fever
Seizures
Shingles
Sickle Cell Disease / Traits
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis (TB)
Ulcers
Venereal Disease
Please list any serious medical condition(s) that you have ever had
Allergies

Are you allergic to any of the following?

Aspirin
Erythromycin
Penicillin
Codeine
Jewelry/Metals
Tetracycline
Dental Anesthetics
Latex
Other
Please list any other drugs / materials that you are allergic to

5. DENTAL HISTORY

Dental History
Why are you coming to the dentist today?
Are you currently in pain?
Do you require antibiotics before dental treatment?
Your current dental health
Have you ever had a serious / difficult problem associated with any previous dental work?
Do you floss daily?
Do you brush daily?
Type of bristles on your toothbrush?
Have you ever had gum treatment?
Do your gums ever bleed?
Do your gums ever itch?
Have you ever had periodontal disease?
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?
Are your teeth sensitive to heat, cold, or anything else?
Do you have any loose teeth?
Do you still have wisdom teeth?
Would you like fresher breath?
Would you like whiter teeth?
Are you happy with the way your smile looks?
If not, what would you change?


Agreement

Payment is due in full at the time of treatment unless prior arrangements have been approved.
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.
I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment.
I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company.
Please note that we require at least TWO business days to change your appointment. I acknowledge and agree to be charged for no show appointments.