Patient info

Eleven Eleven Dental
1111 Columbia Street, Port Angeles, WA 98362 (360) 457-3183 Fax (360) 457-6875 Confidential Patient Information
Patient's Name__________________________________________________________________________________________ Address________________________________________________________________________________________________ Home Phone____________________________Birthdate___________________Social Security #________________________ Work Phone____________________________Cell Phone_______________________e-mail____________________________ I give permission to use my e-mail for correspondence and to confirm appointments. Yes No _________________________ If patient is a minor, give parent's or guardian's name____________________________________________ Whom may we thank for referring you to our office_________________________________________________________________________ Dental History
Reason for visit-Check up_____Relief of Pain____Other_____________________________________________________ Name and address of previous dentist_____________________________________________________________________ Are you happy with the appearance of your smile?___________________________________________________________ Date of last exam__________________________________Date of last x-rays_____________________________________ Is there any aspect of your prior dental treatment that you especially liked or disliked?_______________________________ Medical History
Physician___________________________________________ Office Phone(_____)_____-________________________ Date of last physical exam _______________________________ Have you had or do you have any of the following conditions? ( Circle Yes or No)
Type_______________ How Long ___________ How Much _____________ Please list any medications your are currently taking____________________________________________________________ ______________________________________________________________________________________________________ Have you ever been prescribed the following medication? Fossamax Actonel Boniva Didronel Skelid Aredia Are you allergic or have you experienced adverse reactions to the following:
Confidential Responsible Party Information
Name________________________________________________________________________Marital Status________ Residence_________________________________________________________________________________________ Mailing Address____________________________________________________________________________________ How long at this address? ________Home Phone____________________Work Phone____________________________ Cell Phone_____________________Email Adress_____________________Other_______________________________ Previous (if less than 3 years)__________________________________________________________________________ Social Security #________________________Birthdate___________________Relationship to Patient_______________ Employer_____________________________Occupation_____________________No. Years Employed_______________Spouse's Name_______________________________________________________Relationship to Patient____________ Employer___________________________________________________________Relationship to Patient____________ Social Security #________________________Birthdate________________________No. Years Employed____________ Insurance Information
Policy Holders Name_______________________________________________Social Security_____________________ Insurance Company________________________________________Group No.___________Union Local No_________ Insurance Company Address___________________________________________Insurance Co. Phone_______________ Policy Holder's Employer_____________________________________________________________________________ Do you have duel coverage? No___ Yes ____ Policy Holders Name__________________________________________Social Security__________________________ Insurance Company____________________________________________Group No.___________Union Local No_____ Insurance Company Address__________________________________________Insurance Co. Phone________________ Policy Holder's Employer____________________________________Employers Phone #_________________________ Emergency Information
Name of nearest relative not living with you____________________________________________________________ Address________________________________________________________________________________________ Phone____________________ Cell phone ___________________ I certify that I have read and understand the above information to the best of my knowledge. The above question 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 my child or me during the period of such dental care to the party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist, 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 the payment of all services rendered on my behalf or my dependents.
I understand that where appropriate, credit bureau reports may be obtained.
Signature (Parent's signature if minor)_______________________________________________________

Source: http://www.1111dental.com/Patient_forms_files/H%20Hx2.pdf