Welcome to Bihm Family Dental! Patient Information Patient: Date of Birth: Home Addres city: State: Phone #:(Home)______——_—(Cell)__— Patient's Social Security Marital Status Primary Insurance Company ‘Name: Phone: ‘Name of covered employee: Relationship: Employer Name: Group Number: Social Security # of covered employee: & DOB: Secondary Insurance Company Name: Phone: name of covered employee: Relationship: Employer Name: Group Number: social security # of covered employe DOB: How did you hear about our office? Email address: ‘Afpatientis under 18: Mother's Name: Mother's Phone: Father's Name;_________________Father’s Phone Legal Guardian (other): Guardian’s Phon Guardian/Parent DOB:_ Patient's Medical Information Physician's Name and Contact#: Do you presently have or ever had a history of any of the following? Please circle all that apply YN Abnormal Bleeding Y oN Cancer YN ADD/ADHD YN Chemical Dependency YON AIDS/HIV YN Chemotherapy Y oN Anemia YN Crohn's Disease YON arthritis YN Circulatory Problems YN Artifcial Joints /Valves YN Congenital Heart Defects YN Asperger’s/Autism YN Cough(bloody) Y oN Asthma YN _ Diabetes YN Blood Disease YN _Dizziness/Fainting YN Emphysema YN. Radiation Treatment YN _ Epilepsy/Seizure Disorders YN" Respiratory Disease Y —N Gastrointestinal Disorders YN Rheumatic Fever YN Glaucoma YN Scarlet Fever YN Headaches/Migaines YN Shortness of Breath YN Heart Murmurs YN Sinus TroubleYN Heart Disease/Pacemaker YN Skin Rash YN Hepatitis Type _ Y —_N_ Special Diet/Restrictions YN Herpes Type Y oN Stroke YN Jaundice YN Swelling (glands, feet) YN JawPain YN Thyroid Problems YN Kidney Disease YN Tonsillitis Y —N__Liver Disease YN Tuberculosis YN Tigh Blood Pressure ¥ —-N-—— Tumor of Growth YN Mental Disabilities Y oN Uber YN Mitral Valve Prolapse YN Venereal Disease/STDs Y —N-_ Nervous Disorders/Anxiety YN Weight Loss/Gain In the space provided below, please provide any additional medical Has the patient been hospitalized within the last five years? Y = N Patient's Dental Information Name of Previous Dentist/Dental Clinic: Why are you here to see the dentist today? ‘When was your last dental visit? What was done?. ‘IfFomale: Are you pregnant or trying to become pregnant? YN If'so, due date? Ifnot pregnant, are you taking birth control? = YN Are you breastfeeding: yon PLEASE LIST ANY MEDICATIONS PATIENT IS CURRENTLY TAKING Aspirin Codeine_—_Dental Anestheties Latex Metals/Nickel Penicillin Sulfa Erythromycin other:affirm that the information I have given is correct to the best of my knowledge. The iformation given will be for use in my (or my child's) treatment, billing and processing of insurance benefits to which I (or my child) am entitled. Information will be held to the strictest confidence, and itis my responsibility to inform this office of any changes in my ‘medical status (or my child's medical status). I authorize the dental staff to perform the necessary dental services that I (or my child) may need. Printed mame Patieat/Parent/Guardian) Signature Date Bihm Family Dental 1, consent to be a patient at the above named office and agree toa radiographic and clinical examination. 1 also understand and consent to the following: + During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), restorative dentistry, temporomandibular disorder treatment, oral pathology, pediatric dentistry, and radiography. * will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history. ‘© No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results. * [will pay in full any cost of treatment or insurance copayments according to the office's financial policy. I understand that even if an insurance pre-estimate is given ora procedure has been pre-approved, | am responsible for any costs that my insurance does not cover. ‘© My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff ’ * Lam welcome to ask questions about any aspects of my dental care and will request information if am confused or need more information. Iam responsible for clarifying any aspects of my treatment that lam unsure about. Patient or Guardian Name Date Witness DateBihm Family Dental teaproer oma serv ear rue deh srry nd esata elo ya HN po your peta ‘Settrmaton Ara cored ony wemutiora al patel har igheepteara manos arbi Yeu ‘sey dana pra do ng wi cn nn oar an nemo nature nd pn mao, ed rere tight ‘Autgeer pace rg wate hanimedoanyangrinntmce Wei online eat ound or Wee he spe Scene ‘hosed bear ema newine Trnen we may ue your inornaon dvi e oust wate. 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Ye eu ste wing a xa wh scald be enn nd ‘Rash ear ray arr fel aol vena onl rays Dior ou hath iho roti ef hr an nie om wai dnd oar pera ens rt, Te diese ony Incheon ppm or esos Tn somes ib rn nan ocelna freee, Weve e rit argelere ‘Nowead oor anenris sib ont pee ‘ass Pease contacter eyo ay esos aoa ye hat we have ltd pry en an tia writen cont te {bare fat ae Hin Serv Wem rvs osteo pen os -Aeoonleet oct Rotel ry ress ‘sone bil acne tat avec reenter. age wh heres ete saunders my ihe undr ee Britt ems ry minor as jaa oprid or tnd a ae Name: Signature. Relationship to Fationt: Date: we are unable to get your acknowledgement than our office will make a notation as to why itwas not obtained here Taafftiame: Signature: Date:Office Policies In order for our office to provide you and your family with the best dentistry available to us, we have developed the following policies to help our practice run smoothly and truly help those who are the ‘most willing to receive dental treatment. Missed Appointment Policy Ifyou fail to show up for your scheduled appointment, or fall to give a proper 24-hour in advance call notice, then itwill be counted as a missed /broken appointment on your record, and you may also be assessed a $25 fee. Ifa second appointment is missed under the same conditions, then you will be dismissed from our office and have to seek dental treatment elsewhere. We understand emergencies happen and will take them into consideration, but please be aware that this is time that could have beon given to another patient. Late Arrival Policy Ifyou arrive 15 minutes late for your appointment, then you will be asked to reschedule. It is not fair to those scheduled after you if we have to delay the start of their treatment. If you arrive late, but less than 15 minutes from the scheduled start time, we will try to fit you in, but we cannot promise that ‘we will be able to perform all the planned or necessary treatment. If you are late for three different appointments, then you will be dismissed from our office and have to seek dental treatment elsewhere. We understand that there are many reasons that could be responsible for your late arrival; therefore we ask that you leave your house with plenty enough time to accommodate traffic and any other unforeseen events. Thave read and understand my participation requirements in the above office policies. Signature of Patient or Parent/Guardian Date