Health History Form | Alliance Dental

Health History V1.1

Name(Required)

Birthdate(Required)

Marital Status(Required)

Single

Married/Common-Law

Child

Preferred Office Location(Required)

Form Filled by(Required)

Patient

Parent

Guardian

Parent/Guardian(Required)

Address(Required)

Street Address City Postal Code

Phone - Home

Phone - Work

Cell(Required)

Email(Required)

MSI Health Card Number

(For children 15 and under)

Dental Insurance Benefits Provider

(Ex. Blue Cross)

Group Insurance Holders Name

(If Different From Above, ex. Spouse or Parent)

DOB

Policy Number

Identification Number

Emergency Contact

Emergency Contact Phone #

NEW PATIENTS

How did you hear about us

Sporting Event Sponsor (which one)(Required)

HEALTH HISTORY

Are you having any dental/oral discomfort at this time?(Required)

Yes

please describe below.(Required)

Previous Dentist

Date of last Dental Exam

Date of last Dental X-Rays

What was done at that time?

What is the reason for your Dental Visit today?(Required)

Do you experience any of the following?(Required)

Select all that apply

Have you had any of the following?(Required)

Select all that apply

Are you in good health?(Required)

Last date of physical exam?

Are you being treated by a physician now?(Required)

Yes

Are you currently taking any medications?(Required)

Yes

Please include any over the counter medications

Have you ever been told you need a Pre-Med prior to Dental Treatment?(Required)

Yes

Do you have any allergies?(Required)

Yes

Please list allergies

Are you allergic to any of the following drugs?

Please Check All That Apply

Other (Please Specify)(Required)

Are you allergic to latex?(Required)

Yes

Have you ever taken medication for osteoporosis or bone density?(Required)

Group of drugs used to slow down or prevent bone loss/strengthening bones

Yes

Have you ever had excessive bleeding?(Required)

Yes

Are you currently on any blood thinners or anticoagulants(Required)

Yes

Have you had surgery within the last five years?(Required)

Yes

If YES was it for any of the following reasons?(Required)

Pace Maker

Artificial Heart Valve

Knee/Hip Replacement

Other

Have you ever had any of the following conditions?(Required)

Please Check All That Apply

Have you ever been treated for a tumor or skin disease?(Required)

Yes

Has anyone in your family ever had diabetes?(Required)

Yes

If yes please detail who below

Has anyone in your family had heart disease?(Required)

Yes

Do you take medication for high cholesterol?(Required)

Yes

Do you smoke/chew tobacco?(Required)

Yes

Do you clench or grind your teeth?(Required)

Yes

Do you use recreational drugs or cannabis?(Required)

Please let the hygienist and/or dentist know of any past or current drug use

Yes

Who is your Family Doctor?(Required)

Phone #:(Required)

WOMEN ONLY

Are you pregnant?

Yes

Have you reached Menopause?

Yes

OTHER INFORMATION

Is there anything else in your health history we should know?

Do you have any concerns regarding your dental health?

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Name

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Name

Signature(Required)

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Date

Patient Consent

It may become necessary to refer you to a specialist at some time. In this event, we would be required to provide your personal information, i.e. name; address; date of birth and insurance details. Please sign below indicating your permission for this office to share your personal information for such a purpose. Personal information is shared ONLY with professionals who will be treating you on our behalf. I agree to have my personal information disclosed to and discussed with my immediate family, should it become necessary.

Agree/Disagree(Required)

AGREE

DISAGREE

Confidentiality Policy

We take your privacy very seriously and have policies in place to safeguard your personal information.

If you have dental insurance, it will be necessary for us to share some personal information (i.e. name, address, date of birth, treatment provided, and insurance details) in order to process your claim.

It may become necessary to refer you to a specialist at some time. If you agree to such a referral, we would be required to provide the specialist’s office with the above information, as well as your pertinent dental and medical history. Personal medical and dental information is shared ONLY with professionals who will be treating you on our behalf.

In the unlikely event of a medical emergency, we may need to contact and share information with immediate family members or your emergency contact person.

Please initial below indicating permission for this office to share your personal information, only as described above.

I understand and agree to the Confidentiality Policy outlined above

Initial(Required)

Payment Policy

In an effort to continue to provide quality care and convenience to our valued patients, we will send your insurance claims electronically, thereby allowing us to advise you of the unpaid amount.

We would appreciate the amount not covered by your insurance to be paid in full by you at the time of your appointment.

If you are not covered by dental insurance, we would appreciate receiving payment at the time of your appointment.

If you would like to settle your account by credit card, please advise the receptionist of the number.

Any other payment options should be discussed with the dentist.

I have read and agree with the payment options and patient consent policy above.

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Name

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Name

Signature(Required)

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Date

Acknowledgment of Cancellation Policy

At Alliance Dental we understand that your life is busy and know that occasionally you may need to reschedule or change your appointment time.

Please keep in mind that when we schedule your appointment, we reserve this time especially for you and book our dental professionals to be available for your treatment. If you cancel without notice we lose two appointments, your appointment and the person who would have been scheduled for that time slot.

Please carefully read the following Cancellation Policy:

I am responsible for providing 24-hours notice of appointment cancellations.

I acknowledge that if I do not provide 24-hours notice, I may be charged a cancellation fee. The fees range from $25 per appointment to $75 per appointment based on the length of my scheduled appointment.

I also acknowledge that my insurance may not pay for cancellation charges I may incur, and that I will be personally responsible for paying such cancellation charges.

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Name

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Name

Signature(Required)

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Date(Required)