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Gebfert-Park Family Dentistry
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Welcome to Our Practice!
(260) 490-4440
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The benefits of a happy, healthy smile are
immeasurable!
Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate the better we can care for you.
About you, the patient:
Name:
*
I prefer to be called (if applicable):
Gender
*
Male
Female
Other
Date of birth
*
Social Security Number:
Marital Status
*
Single
Married
Address
*
Main Phone
*
Cell / Other
Email:
Dental Insurance Info
Primary Dental Insurance
Insurance CO. Name:
Insurance CO. Address:
Insurance CO. Phone:
Group #:
Subscriber Name:
Birthday:
Subscriber ID:
Employer:
Secondary Dental Insurance (if applicable)
Insurance Company Name:
Group #:
Phone Number:
Insured's Name:
Insured's Birthdate:
Subscriber ID:
Employer:
Employer Info:
Company:
*
Address:
*
Phone:
*
Ext:
Spouse Info:
Name
Employer
Work Phone
Ext:
Birthdate:
Spouse SS #:
Responsible Party
Name of person responsible for account:
*
Relationship to patient:
Billing Address
*
Main Phone
*
Other Phone / Cell
Employer
*
Birthdate
*
Dental History
Reason for today's visit:
*
Are your teeth sensitive to:
Cold
Hot
Sweets
Biting
Does food collect between your teeth?
*
Yes
No
Have you ever had excessive bleeding after a dental extraction?
*
Yes
No
Have you ever had experienced pain in your jaw joint (TMJ)?
*
Yes
No
Have you ever had a problem with previous dental work?
What do you like least about your teeth?
Have you ever considered teeth whitening?
*
Yes
No
Last visit date
*
Previous Dentist:
Medical History
Name of physician:
Last physical date
Are you currently under care of a physician?
*
Yes
No
If so, what is the condition being treated?
Have you been hospitalized in the last 5 years?
*
Yes
No
If so, what is the condition being treated?
List any over-the-counter medicines or prescriptions you may be taking
List any you may be allergic to:
Penicillin
Tetracycline
Aspirin
Erythromycin
Codeine
Nickel
Latex
Dental Anesthetics
List any other antibiotics you may be allergic to:
List any other allergies you are aware of (food, pollen, etc...):
For women:
Do you take birth control?
Yes
No
Are you pregnant
Yes
No
To your knowledge, have you ever had any of the following medical conditions?(Select all that apply):
List any you may be ailed by:
Artificial Joints
Abnormal bleeding
AIDS, HIV Positive, ARC
Ear or Eye Problems
Epilepsy
Blood Transfusion
Drastic Weight Change
Severe/Frequent Headaches
Abnormal Blood Pressure
Heart Attack
Stroke
Mitral Valve Prolapse
Rheumatic Fever
Fainting Spells, Seizures
Chemotherapy
Venereal Disease
Heart Murmur
Congenital Heart Defect
Hepatitis
Kidney, Urinary or Bladder Problems
Nervous or Mental Disorders
Respiratory Disease or Tuberculosis
Radiation Therapy
Asthma
Ulcers/Colitis
If any above are selected, why?:
Do you have any other medical conditions not above that we should know about?
I realize that my insurance company, if any, has an obligation to me and not to the dentist. This office has no contractual arrangement with insurance carriers, therefore I am responsible to this office for payment of services rendered. I authorize this dental staff to perform any necessary dental services with my informed consent that I need during diagnosis and treatment.
Sign below to agree to the terms above and certify all information is correct:
Clear Signature