As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Youranswers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses tothis questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This officedoes not use this information to discriminate.
Do you have any of the following diseases or problems:
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis
If you answer yes to any of the 4 items above, please stop and contact the receptionist.
Date of last dental X-Rays
Patient's relationship to insured: Self Spouse Child Other
By checking this box, I authorize my insurance company to pay the dentist all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authroize the dentist to release all information necessary to secure the payment benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Check here if you prefer to fill out the insurance paperwork at the office.
Check here if you do not have insurance.
Do you wear contact lenses?
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease?
Do you use controlled substances(drugs)?
Are you allergic to or have you had a reaction to: Local Anesthetics Aspirin Penicillin or other antibiotics Barbiturates, sedatives, or sleeping pills Sulfa Drugs Codeine or other narcotics Metals Latex (Rubber) Iodine Hay fever/seasonal Animals Food
Please check your response to indicate if you have had any of the following diseases or problems:
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
Has a physician or previous dentist recommend that you take antibiotics prior to your dental treatment?
How did you hear about our office?
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful healthhistory and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forthabove have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do nottake because of errors or omissions that I may have made in the completion of this form.
Choose a location.
Location: Bolingbrook, IL Office Chicago, IL Sister Office Franklin Park, IL Office Plainfield, IL Office
The consent forms that are located in the locations pages in the registration menu need to also be printed out and brought in to make things more smooth when you arrive for your appointment. We would appreciate that very much.