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PRINT OUT FORM - COMPLETE FORM - BRING FORM TO APPOINTMENT
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DENTAL AND MEDICAL HISTORY
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Acacia Endodontics, Lance P. Schneider, D.D.S. / Shaun R. Cullimore D.M.D.
(This confidential information is for our records only)
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Name of Patient: __________________________________________________
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Date: ____________________
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(Name of parent or guardian if patient is under 18)
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Mailing address: _____________________________________________________________________________
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Marital Status: _______________
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Birthdate: ____/____/________
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Home phone: ______________________________________
Occupation: _______________________________________
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Work phone: _____________________________
S.S.N.: __________________________________
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Employer & Address: _____________________________________________________
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Spouse or parent: ________________________
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Person responsible for this account: _______________________
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Relationship: __________________________________________
Phone (home): _________________________________________
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S.S.N.: ______________________________
(work): ______________________________
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Address(if different): ____________________________________________
Employed by: _________________________________________________
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Date of birth: ____/____/________
How long: ___________________
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Primary: _________________________________________
Secondary: _______________________________________
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Policy Number: ____________________________
Policy Number: ____________________________
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Referred by: ________________________________________________________________________________
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I understand root canal treatment is a procedure to retain a tooth which may otherwise require extraction. Although root canal therapy has a very high degree of clinical success, it is still a biological procedure so it cannot be guaranteed. Occasionally , a tooth which has had root canal therapy may require retreatment, surgery or even extraction.
I also understand that only the root canal treatment is to be performed in this office. The permanent (outside) restoration (filling, inlay, crown, etc.) will be done by my regular dentist.
I also acknowledge full responsibility for the payment of such services and agree to pay for them, in full, at or before completion, unless other specific arrangements are made with the office manager.
I agree to pay reasonable attorney fees, court cost and collection cost (to 40% of the outstanding balance) should collection action become necessary.
I authorize my insurance carrier to issue the dental benefits of my plan directly to this dental office. I also authorize release of any information necessary to process dental insurance.
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I wish to pay for dental treatment by:
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A billing charge of 1.5% per month (annual percentage rate of 18%) is assessed on all balances carried over 90 days.
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Signature: ___________________________________________________
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Date: ________________________
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Parental permission: ___________________________________________
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Dental and Medical History
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Yes No Are you in good health?
Yes No Are you currently undergoing medical treatment of any kind?
Describe: ________________________________________________________________________
Name of you physician: _____________________________________________________________
Yes No Are you sensitive or allergic to: penicillin, novocaine, codeine, aspirin,
or any other medication?
Describe: ________________________________________________________________________
Yes No Do drugs make you feel nauseated?
Yes No Do you have dizziness or fainting spells?
Yes No Have you had any problems with previous dental treatment?
Yes No Have your teeth been difficult to numb in the past?
Yes No Do you use alcohol and/or drugs regularly?
Yes No Are you subject to prolonged bleeding?
Yes No Female patient: Are you pregnant? Month due: _______________
Yes No Female patient: Are you breastfeeding?
Yes No Have you ever had artificial prosthesis, hip replacement, heart valves,
other: __________________________________________________________________________
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Asthma
Sinus problems
Allergies
X-ray or Cobalt treatment
Cancer
Stroke
Anemia
Ear trouble
Heart murmur
Hepatitis/Jaundice
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Rheumatic Fever
Scarlet Fever
Heart trouble
Nervous disorders
Psychiatric Care
Venereal disease
Glaucoma
Frequent headaches
Angina (chest pain)
Kidney or bladder trouble
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Arthritis
Diabetes
Tuberculosis
Ulcers/Colitis
High blood pressure
Herpes infection
Epilepsy/convulsions
Bleeding disorders
Alcoholism/Drug dependence
Viral infections
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Acquired Immune Deficiency Syndrome
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Please list the prescription and/or OTC medications you are currently taking:
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1. _________________________________________
2. _________________________________________
3. _________________________________________
4. _________________________________________
5. _________________________________________
6. _________________________________________
7. _________________________________________
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____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
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Yes No Have you ever had root canal treatment before? __________________________________________
_______________________________________________________________________________
What is your present dental problem? __________________________________________________
_______________________________________________________________________________
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This form completed by (signature): ________________________________________________
If not the patient, please give relationship: ___________________________________________
Date: _________________
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