Proudly serving Dripping Springs and Surrounding Communities for over 15 years! Patient Information

~Welcome~
Dripping Springs Family Dentistry, Inc.

Proudly serving Dripping Springs and Surrounding Communities for over 15 years!

Patient Information (CONFIDENTIAL)

Name _______________________________________________________ Birth date_____________

Address ___________________________________City _________________ State ____ Zip Code ______

Email _________________________________Cell Phone _______________Home_________________

Please circle: Male/Female Minor/Single/ Married/ Divorced/ Widowed/ Separated

Emergency Contact Name: _______________________Phone_____________Relationship___________

Whom me we thank for referring you?_____________________________________________________

Patient Medical History

Physician _______________________Phone _________________ Date of Last Exam ___________

1. Are you under medical treatment now? Yes/No If yes, please explain_______________________________

2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? Yes/No

If yes, please explain________________________________________________________________________

3. Are you taking any medication(s), including non-prescription medicine? Yes/No____________________________________

4. Women only: A) Are you pregnant or think you are pregnant? Yes/No B) Are you nursing? Yes/No C) Are you taking oral contraceptives? Yes/No

Please circle yes or no to the following questions:

Do you use tobacco products/VapCigs? Yes/No Do you use controlled substances? Yes/No Type________________________ Are you allergic to or have you had any reactions to any of the following:

Local Anesthetics (Novocain) Yes/No Penicillin Yes/No Sulfa Drug Yes/No Barbiturates Yes/No

Sedatives Yes/No Iodine Yes/No Aspirin Yes/No Any Metals (nickel, mercury, etc.) Yes/No Latex Yes/No

Other (Please List)_________________________________________________________________________

High Blood Pressure Yes/No Heat Attacks Yes/No Rheumatic Fever Yes/No Swollen Ankles Yes/No Fainting/Seizing Yes/No Dizziness Yes/No Asthma Yes/No Low/High Blood Pressure Yes/No

Epilepsy/Convulsions Yes/No Diabetes Yes/No Kidney Diseases Yes/No AIDS or HIV Infection Yes/No

Thyroid Problem Yes/No Heart Disease Yes/No Cardiac Pacemaker Yes/No Heart Murmur Yes/No Angina Yes/No Anemia Yes/No Emphysema Yes/No Cancer Yes/No If yes, type_________________ Arthritis Yes/No

Joint Replacement Yes/No Hepatitis Yes/No Type_____ Jaundice Yes/No Stomach Trouble/Ulcers Yes/No

Chest Pains Yes/No Easily Winded Yes/No Frequently Tired Yes/No Stroke Yes/No Hay Fever/Allergies Yes/No Tuberculosis Yes/No Radiation Therapy Yes/No Glaucoma Yes/No Liver Disease Yes/No Head Injuries Yes/No Mental Disorders Yes/No Nervous Disorder Yes/No Blood Disease Yes/No Recent Weight Loss Yes/No Liver Disease Yes/No Respiratory Problem Yes/No Mitral Valve Prolapse Yes/No Tumors Yes/No Sexually Trans. Disease Yes/No

Any other not listed_______________________________

Insurance Information

Primary Insurance Information

Name of Insured __________________________Cell Phone_____________Relation to Patient_______

Insured’s Address ___________________________City _____________ State______Zip Code ________

SS# ________________ DOB__________Name of Employer____________________________________

Address of Employer ______________________________City_____________State____Zip Code______

Insurance Company _______________________Group# _______Sub/Member ID#/________________

Ins. Co. Address ___________________________City _______________ State ___ Zip Code_________

Secondary Insurance Information

Name of Insured __________________________Cell Phone_____________Relation to Patient_______

Insured’s Address ___________________________City _____________ State______Zip Code ________

SS# ________________ DOB__________Name of Employer____________________________________

Address of Employer ______________________________City_____________State____Zip Code______

Insurance Company _______________________Group# _______Sub/Member ID#/________________

Ins. Co. Address ___________________________City _______________ State ___ Zip Code_________

Responsible Party

Name________________________________________________________ Birth date __________

Relation to Patient ______________________

Address ___________________________________City _____________ State______Zip Code ________

Cell Phone ___________________ Work Phone_________________Email ___________________________

Employer Name:__________________________Occupation_________________

Address ___________________________________City _____________ State______Zip Code ________

Patient Dental History

Name of Previous Dentist and Location ________________________________Date of Last Exam ___________

Please circle yes or no to the following questions:

Do your gums bleed while brushing or flossing? Yes/No Do you have frequent headaches? Yes/No

Are your teeth sensitive to hot or cold liquids/foods? Yes/No

Are your teeth sensitive to sweet or sour liquids/foods? Yes/No

Do you feel pain to any of your teeth? Yes/No

Do you have any sores or lumps in or near your mouth? Yes/No

Have you had any head, neck or jaw injuries? Yes/No If yes please explain_____________________________________

Have you ever experienced any of the following problems in your jaw?

Clicking Yes/No Pain (joint, ear, side of face) Yes/No Difficulty in opening or closing Yes/No Difficulty in chewing Yes/No

Do you clench or grind your teeth? Yes/No Do you bite your lips or cheeks frequently? Yes/No

Have you ever had any difficult extractions in the past? Yes/No

Have you ever had any prolonged bleeding following extractions? Yes/No

Have you had any orthodontic treatment (braces)? Yes/No

Do you wear dentures or partials? Yes/No If yes, date of placement _____________________

Have you ever received oral hygiene instructions regarding the care of your teeth and gums? Yes/No

Do you like your smile? Yes/No If no please explain______________________________________________________________

Authorization and Release I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of Patient/Guardian X___________________________________________ Date _______________