Emergency Call
Patient Form

Patient form

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Prefix
Patient Name
Sex
Address
Have you ever been a patient of our practice?
Has a family member ever been a patient of our practice?
Referred By
Dentist
Orthodontist
Medical Dr.
Personal Payment Type
Nearest relative not living with you name/phone
In case of emergency, please contact

Who Will Be Responsible For Your Account

Relationship
Name
Address

Spouse or other guarantor information (if different from above)

Relationship (copy)
Name (copy)
Address (copy)

Insurance Information

Employed
Marital Status
Address

Is there a family history of:

Cancer?
Diabetes?
Heart disease?
Anesthesia problems?

Medications

Have you ever taken diet pills?
Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)?
Have you ever taken diet pills?
A natural product, herbal supplement, or homeopathic remedy?
Are you taking or have you ever taken, bone density meds. or bisphosphonates such as Fosamax, Boniva, Actonel, IV-Zometa, or Aredia in the past 12 years?

Are you allergic to, or had a reaction to:

Local anesthetic (numbing meds.)?
Other antibiotics?
Penicillin?
Sulfa drugs?

Health History

If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?
Is there any condition concerning your health that the Doctor should be told about?
Do you wish to speak to the Dr. privately about anything?
Is this visit related to an accident?
If Yes, what type of accident?

Signatures

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.
We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.
This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.