Patient Information

Date:
 
Last Name First Name Middle Name  
 
ADDRESS
  Street Apt. # City State Zip
 
BIRTHDATE
  Month Day Year
TELEPHONE
  Home # Work # Fax # E-mail
 
PLACE OF EMPLOYMENT
 
IF FULL TIME STUDENT, SCHOOL NAME
GRADE
 
PERSON RESPONSIBLE FOR ACCOUNT - PLEASE CHECK ONE:
PATIENT GUARDIAN SPOUSE FATHER MOTHER
 

Insurance Information

Minor Child - May need To Complete Both Blocks For Parent Information
Adults - Complete Primary Insured
Dual Coverage? Also Complete Secondary Insured

Primary Insured / If No Insurance Complete for Responsible Party
 
Last Name First Name Middle Name
 
Street City State Zip
 
Home # Work # Fax # E-mail
 
Birthdate (Month/Day/Year) Relationship to Patient
 
Employer Dental Ins. Co
 
Subscriber# Group#
 
 

Secondary Insured
Last Name First Name Middle Name
 
Street City State Zip
 
Home # Work # Fax # E-mail
 
Birthdate (Month/Day/Year) Relationship to Patient
 
Employer Dental Ins. Co
 
Subscriber# Group#
 

Person To Contact In Case Of Emergency

Outside of Immediate Family Household
 
Name:
 
Adress:
 
City / State / Zip
 
Telephone #
 
Has any member of your family ever been treated in our office?
 
Whom may we thank for referring you to our office?
 

Stephens and Gatewood Financial Options

As a courtesy, we will be happy to assist you in filling your dental insurance. We are an out of network provider for all insurance companies except Delta Dental. We collect your estimated portion on the day of service and will wait 30 days to obtain the balance from your insurance. The patient or guarantor is responsible for the entire fee. Any portion not paid by your insurance company in 30 days will be collected from the patient. Dr. Stephens and Dr. Gatewood will provide dental care based on your dental needs and will not be based on your insurance coverage. Our goal is to provide you with exceptional service in obtaining excellent oral health.

We Accept:
  • Cash
  • Personal and Business Checks
  • Visa, Mastercard, American Express, & Discover
  • Extended financing available with Wells Fargo and Care Credit for services over $300

Authorization

I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payors and/or other health professionals by any method, including electronic transfer.

 
Date
 

Patient History

PATIENT NAME Date
Primary reason for this dental appointment:

Dental History

 Please Select
Do you have a specific dental problem? Describe
Do you have dental examinations on a routine basis?
Last visit
Do you have frequent headaches?
Do you brush and floss on a routine basis? Discuss
Do your gums ever bleed? Discuss
Do you like your smile? Why?
Does food catch between your teeth? Any loose teeth?
Do you want to keep your remaining teeth?
Do you ever have clicking, popping discomfort in the jaw joint? Do you brux or grind?
Have your past experiences in a dental office always been positive?
Do you smoke or chew? Any sores or growths in your mouth? Discuss
Are there any fears we need to be made aware of?
Name of Previous dentist (Optional) :
Date of last full mouth x-rays (16 small films or panoramic) :

Medical History
Are you under a physician's care now? Why?
Who? Phone
Have you ever been hospitalized or had a major operation? Discuss
Have you ever had a serious injury to your head or neck? Discuss
Are you taking any medications, pills or drugs? What?
Are you on a special diet? Discuss
Are you allergic to any medications or substances? Please check box below
Women (Please check):
What trimester?
Do you now have or have you ever had any of the following? Please check appropriate boxes.
*if yes to any of the starred conditions, please call prior to your appointment… premedication may be required.
Yes No
Anemia*
Arthritis*
Artificial Heart Valve*
Asthma*
Cancer*
Cold Sores/Fever Blisters*
Dizziness*
Emphysema*
Excessive Bleeding*
Fainting*
Head Injuries*
Heart Murmur*
Hepatitis A, B or C*
High Blood Pressure*
Yes No
Kidney Disease*
Latex Sensitivity*
Pacemaker*
Radiation Treatment*
Respiratory Problems*
Sinus Problems*
Smoke/Chew Tobacco*
Stroke*
Thyroid Problems*
Tumors*
Ulcers*
Codeine Allergy*
Penicillin Allergy*

Allergic/Adverse reaction to medication or any substance If so, what?
Have you ever had any other serious illness not checked above? Discuss
Do you wish to talk to the dentist privately about any problem?
Any other serious illness/condition not listed above? Discuss

To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail.
Reviewed By Doctor Date: BP
History Review and Significant Findings

Medical Updates
I have read my MEDICAL HISTORY dated and confirm that it adequately states past and present conditions.

All major credit cards accepted.

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