Patient Paperwork

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HUGH J. HOWARD D.D.S.

144 South State St. La Verkin, UT 84745
(435) 635-4244 www.hughhowardds.com
Facebook.com/hughjhowardds

PATIENT INFORMATION

First Name (required)

M.I.

Last Name

Birth Date

(Check all that applies)

Sex:  Male Female Minor Single Married

Street Address

City

State

Zip

Email

For Future appt. reminders, I prefer to be notified via  text email phone call

Cellphone

Home phone

Work phone

Employer

Driver's License Number

State

Social Security Number

In case of emergency, who should be notified?

Name

Phone

Relationship to Patient

Payment Method  Cash Credit Card/Debit Card Care Credit Check

I hereby authorize assignment of my insurance rights and benefits directly to Hugh J. Howard D.D.S. for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance.


PERSON RESPONSIBLE FOR THIS ACCOUNT

 Check here if address is the same as above

(If patient is a minor under 18, please complete the next section for the child's parent/guardian)

Name

Relationship to Patient

Birthdate

Home Address (if different from above)

Employer

Social Security Number

Driver's License Number

Payment Method  Cash Credit Card /Debit Card Care Credit Check

I hereby authorize assignment of my insurance rights and benefits directly to Hugh J. Howard D.D.S. for services rendered.
I fully understand that I am solely responsible for any balance not paid by my insurance company.


INSURANCE INFORMATION

Dental Insurance  Yes No

Effective Date

Subscriber's Name

Subscriber's Birthdate

Member SS#

Subscriber's Employer

Insurance Company

Insurance Phone Number

Group Number

Member ID#


SECONDARY INSURANCE

Dental Insurance  Yes No

Effective Date

Subscriber's Name

Subscriber's Birthdate

Member SS#

Subscriber's Employer

Insurance Company

Insurance Phone Number

Group Number

Member ID#


DENTAL HISTORY

Approximate date of last dental appointment

Reason for first visit with us

Please add anything that you feel is important for the doctor to know

Please fill in the yes or no circle to the following questions:

Are you having PAIN, SWELLING, or SORE SPOTS at this time?  Yes No

Do your GUMS BLEED?  Yes No

Have you had PERIODONTAL TREATMENTS?  Yes No

Do you have REMOVABLE dentures or partials?  Yes No

Upper

Lower

Is this your FIRST VISIT to any dentist?  Yes No

Have you had any COMPLICATIONS with dental treatment?  Yes No

Have you been treated for TMJ (Temporomandibular Joint problems)?  Yes No

Do you have a FEAR of Dentistry?  Yes No

If yes, why?


MEDICAL HISTORY

Name of Your Primary Care Physician

Phone

Date of last physical

Are you taking any MEDICATIONS now (PRESCRIPTION AND/OR OVER-THE-COUNTER)?  Yes No

If yes, please list

Women: Are you  Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?

Are you allergic to any of the following?  ACRYLIC ASPIRIN CODEINE LOCAL ANESTHETIC LATEX METALS PENICILLIN SULFA OTHER

Are you currently taking Coumadin, Warfarin or other BLOOD THINNERS?  Yes No

Do you have or have had at any time, any of the following?

 Anxiety Alzheimer's Disease AIDS/HIV Positive Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains
 Cold Sores Diabetes Drug Addiction Emphysema Epilepsy/Seizures Bleeding Problems Excessive Thirst Fainting Spells Frequent Cough Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Disease Hepatitis A
 Hepatitis B Hepatitis C Herpes High Blood Pressure Hives or Rash Hyperglycemia Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Pain in Jaw Joints Psychiatric Care
 Radiation Treatments Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Stomach/Intestinal Disease Stroke Thyroid Disease Tonsilitis Tuberculosis Tumors or Growths Ulcers Venereal Disease

Have you ever had any serious illness not listed above?  Yes No

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform Hugh J. Howard D.D.S. of any changes in medical status.

I CERTIFY THAT THE ANSWERS TO THE HEALTH QUESTIONS ARE ACCURATE AND CORRECT TO THE BEST OF MY KNOWLEDGE


 
 
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