Welcome ffffffffffffffffffMichael O’Brien D.D.S.
Patient Information Dental Insurance
Whom may we thank for referring you? Insurance Ph# .
,
Subscriber Name .
Date .
.
Patient Name ID # Group# .
Address Date of Birth Relationship to pt.
.
City Secondary Ins. Ph# .
State Zip Subscriber Name DOB .
SSN# ID# Group# .
Sex: M F Age Date of Birth Relationship to patient .
Minor Single Married Partnered ASSIGNMENT AND RELEASE
Separated Divorced Widowed I certify that I, and/or my dependent(s), have insurance
coverage with ,
Who is responsible for this account? and assign directly to La Mesa Family Dentistry all
insurance benefits, if any, otherwise payable to me for
services rendered. I understand that I am financially
Relationship to Patient responsible for all charges whether or not paid by
insurance. I authorize the use of my signature on all
Occupation insurance submissions. The above-named doctor may use
my health care information and may disclose such
Employer information to the above-named insurance company(ies)
and their agents for the purpose of obtaining payment for
Employer’s Address services and determining insurance benefits or the benefits
payable for related services.
City/State/Zip .
.
Employer’s Phone Signature of patient, parent, or guardian (responsible party):
Spouse’s Name . .
Date Relationship to patient
Date of Birth SSN# .
Spouse’s Employer .
Telephone numbers
Cell .Home Work Ext .
Spouse’s Work E-mail .
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household, if possible)
Name Relationship Cell/Home# Work# __________
Please understand that any expense not covered by your insurance is your responsibility. Your estimated share of cost is
expected on the date services are rendered. Please ask us about different payment options, if needed.
Name .Physicians name Dr.’s Phone Date of last physical .
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?'These include combinations of
Ionamin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes⬜ No⬜
Have you taken any of the bisphosphonate drugs? Aredia⬜ Actonel ⬜Boniva ⬜Fosamax ⬜ Zometa⬜ Other⬜ None⬜
Please indicate if you have experienced any of the following, check yes or no:
Heart Murmur oyes☐ no☐ Kidney Disease yes☐ no☐ Tuberculosis yes☐ no☐
Heart Problems or Surgery yes☐ no☐ Prolonged Bleeding yes☐ no☐ Fainting/Dizziness yes☐ no☐
Congenital Heart Lesions yes☐ no☐ Liver Disease yes☐ no☐ Asthma/Sinus Trouble yes☐ no☐
High Blood Pressure yyes☐ no☐ Psychiatric Care yes☐ no☐ Headaches yes☐ no☐
Low Blood Pressure yes⬜ no⬜ Diabetes: Type . yes☐ no☐ Breathing Problems yes☐ no☐
Mitral Valve Prolapse yes⬜ no⬜ AIDS/HIV yes☐ no☐ Back Problems yes☐ no☐
Artificial Heart Valves yes⬜ no⬜ Thyroid Problems yes☐ no☐ Cancer yes☐ no☐
Pacemaker yes⬜ no⬜ Herpes yes☐ no☐ Difficulty Reclining yes☐ no☐
Rheumatic Fever yes⬜ no⬜ Smoke/Tobacco yes☐ no☐ Radiation Treatment yes☐ no☐
Arthritis, Rheumatism yes⬜ no⬜ Circulatory Problems yes☐ no☐ Hospitalized Recently yes☐ no☐
Drug Addiction yes⬜ no⬜ Emphysema yes☐ no☐ Chemotherapy yes☐ no☐
Stroke yes⬜ no⬜ Anemia yes☐ no☐ Sleep Apnea yes☐ no☐
Shortness of Breath yes⬜ no⬜ Cough, persistent/bloody yes☐ no☐ Cholesterol yes☐ no☐
Artificial Joints yes⬜ no⬜ Epilepsy yes☐ no☐ Hepatitis: Type . yes☐ no☐
Condition not listed? yes⬜ no⬜ .
Women: Are you pregnant? yes☐ no☐ Due Date Nursing? yes⬜ no⬜ Taking birth control pills? yes⬜ no⬜
Medications List medications you are taking and why: None⬜ llergies
A None⬜
Aspirin⬜ Codeine⬜ Penicillin⬜
. Latex⬜ Local Anesthetic⬜
. Sulfa⬜ Iodine⬜ .
Pharmacy Phone Metal⬜ . Other⬜ .
Dental History: Please check “Yes” or “No” to indicate if you have had any of the following:
Teeth whitening yes⬜ no⬜ Braces retainers yes⬜ no⬜ Reason for today’s visit .
Mouth sores or growths yes⬜ no⬜ Broken fillings or tooth yes⬜ no⬜ .
Lip/cheek biting yes⬜ no⬜ Food collection between teeth yes⬜ no⬜ Former Dentist .
Grinding teeth yes⬜ no⬜ Sensitivity cold, heat, sweets yes⬜ no⬜ Last visit .
Chew on one side of mouth yes⬜ no⬜ Bad breath yes⬜ no⬜ Last x rays .
Pain around ear(s) yes⬜ no⬜ Gums swollen, tender, bleeding yes⬜ no⬜ How often do you brush? .
Clicking/popping jaw yes⬜ no⬜ Gum surgery or loose teeth yes⬜ no⬜ How often do you floss? .
Jaw pain/tiredness yes⬜ no⬜ Sensitivity when biting yes⬜ no⬜ City/State .
Do you like your smile? yes⬜ no⬜ If not what would you like to change? .
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have
answered all the questions truthfully and to the best of my knowledge.
Patient signature . Date Staff Signature Date .
Date Any Changes? If yes, please list them Signature
. yes⬜ no⬜ . .
. yes⬜ no⬜ . .
Financial Agreement
Our goal is to provide the highest quality of dental care possible and to have clear
communication of our financial policy.
ALL ACCOUNTS ARE DUE AND PAYABLE AT TIME OF SERVICE. If a procedure requires
multiple appointments, payment is required in full at the first appointment unless a prior payment
arrangement has been made.
Payment options:
1. Cash
2. Check
3. Major credit cards ( American Express, Master Card, Visa, Discover)
4. Care Credit
5. Credit card authorization for recurring charges:
a. Treatment exceeds 400$
b. Plan may not exceed 4 months
Patient with insurance: The PATIENT is responsible for the ESTIMATED non-covered portion,
procedures and /or deductibles at the time of the service, OR the patient can sign a credit card
authorization to bill their credit card AFTER insurance has paid for the visit. If the insurance
company does not pay after 60 days, we will bill you directly for the full balance.
Parents not accompanying their child to an appointment must make PRIOR arrangements
for payment (cash, check or credit card authorization).
Parents accompanying their children are financially responsible for payment.
There is a $30.00 processing charge for non-sufficient funds or returned checks.
Records can be viewed at anytime. There is a nominal charge for release or copies of records.
Broken Appointment Policy:
Because instruments, chairs, and personnel are reserved exclusively for your appointment,
there is a $50 CHARGE FOR CHANGED OR BROKEN APPOINTMENTS LESS THAN 48
BUSINESS HOURS IN ADVANCE.
I, , agree to these financial terms.
Signature , Date .
