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For your
convenience, below are the forms you will need to complete
prior to your first dental appointment. This will assist
the Doctor in properly evaluating your condition to determine
the very best dental health care program for you.
To save yourself some
time, you can print the forms out, fill them in, and bring them
with you for your appointment.
_______________________
__________________________________
Having Problems Printing
the Forms?
If you have problems
printing the forms, it is suggested you try one of the
following methods:
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Above the
forms are offered in Adobe PDF (portable document format) for
your convenience. This is the easiest method to access
and printout the forms. Also, for your convenience, in
the event you do not already have Adobe Acrobat PDF Reader
Software installed on your computer, you can download a free
copy by following the link provided above.
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The
second easiest and assured method is by
hi-lighting the form, followed by copying and pasting into a
blank word document. You can then easily print it out.
(Hi-lighting is
accomplished by holding down the left button of your mouse and
dragging it across the document. Then right click to
copy what you have hi-lighted. Go to the blank word
document and paste it.)
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Below are thumbnail photos of each form. Click on a form
to increase it to full size. Right click on the enlarged
photo and select "save as". You can now save
the form as a photo in your favorite photo folder by giving it
a name so that you can readily retrieve it when desired.
Open
up a "word" document and use the "insert
picture from file" feature on the tool bar to insert the
photo of the selected form into your word document.
Afterwards, the photo can be resized to fill the page within
the margins you have set for your word document. Now it
is ready to be printed out.
Medical History |
Patient Information Card |
Dental Anxiety Scale |
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Chart #__________ |
Patient
Information Card
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Acct # __________ |
PLEASE PRINT
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DATE:___________
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PATIENT INFORMATION |
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Last Name:___________________ |
First Name:__________________ |
Middle Name:__________________ |
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Mailing
Address:_________________________________________
(and Street if P.O. Box) |
City:____________________
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State:______________________ |
Zip: _______________________ |
How Long? __________________ |
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Home Phone___________ |
Work Phone___________ |
Cell Phone____________ |
Other Phone___________ |
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Date of
Birth
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Hair Color
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Eye Color
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Weight
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Height
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Occupation_______________________ |
Employer's
Name____________________ |
Student, FT [ ], PT [ ] |
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Social Security
#___________________ |
DL
#______________________________ |
Exp. Date________ |
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Name:_____________________________________________________ |
Home Phone________________ |
Mailing
Address______________________________
(And Street if P.O. Box) |
City______________________________________
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State______________________________________ |
Zip______________________________________ |
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Employer Name &
Address:_______________________________________________________________ |
| Relationship to
Patient:_______________ |
Occupation:___________________ |
Bus.
Phone______________ |
| Social Security
#______________ |
Date of
Birth:___________ |
Driver's License
#____________________ |
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Cash___________ |
Check___________ |
Sears Card
#________________ |
Visa Card
#________________ |
Master Card
#_______________ |
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Employee Name________________ |
Policy #______________________ |
Social Security #_______________ |
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Employer_____________________ |
Phone #______________________ |
Insurance Co.__________________ |
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Send Claims
To:_____________________________________________ |
Phone #_______________________ |
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I AUTHORIZE
RELEASE OF ANY INFORMATION RELATING TO INSURANCE
_______________________________
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Signed (Patient, or Parent, if Minor)
Date
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I HEREBY AUTHORIZE PAYMENT
DIRECTLY TO THE BELOW NAMED DENTIST OF THE GROUP
INSURANCE BENEFITS OTHERWISE PAYABLE TO ME
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Signed (Insured Person)
Date
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Previous Dentist
Name:_________________________ |
Physician's
Name:_____________________________ |
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Name and Address of Nearest
Living
Relative:___________________________________________________ |
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Is any other member of your
family a patient here? If so, patient's
name_______________________________ |
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Whom may we contact in case of
emergency?________________________________ |
Phone_____________ |
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How Did You
Find Out About The Dentist Place?
(Please Circle)
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1
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You or a family member is
employed by Sears or an affiliate. |
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Yellow Pages
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2
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Referred by a patient.
Who?__________________________________ |
9
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Sears or a Mall shopper and saw
our offices or signs. |
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3 |
Direct Mail. What
type?____________________ |
10 |
Mall Employee |
4
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Brochure
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11
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Referred by one of our
employees.
Who?_____________________________________ |
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5 |
Newspaper |
12 |
Your employer belongs to
Preferred Patients Program |
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6 |
TV |
13 |
Internet |
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7 |
Radio |
14 |
Other |
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Dental Treatment Anxiety Scale
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Name:___________________________________
We strive to make your experience in our
office as pleasant as possible. In order for our staff and
doctors to better handle any anxiety or concern you may have
about having dental treatment, please take a few minutes to
answer the following questions by circling your response on the
graded scale below.
(SCALE)
1 = NOT NERVOUS OR ANXIOUS - - - TO - - - 5 = VERY ANXIOUS OR
NERVOUS
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| 1 |
Entering a dental
office |
1___2___3___4___5___ |
| 2 |
Smell or odor of
dental/medical environment |
1___2___3___4___5___ |
| 3 |
Sitting in the
dental chair |
1___2___3___4___5___ |
| 4 |
Having an
injection of local anesthetic |
1___2___3___4___5___ |
| 5 |
Noise of drill or
other instruments |
1___2___3___4___5___ |
| 6 |
Length of time in
chair for work to be performed |
1___2___3___4___5___ |
| 7 |
Lack of control
over procedure or treatment |
1___2___3___4___5___ |
| 8 |
Concern that it
will hurt while having work performed |
1___2___3___4___5___ |
| 9 |
Concern that you
might get AIDS |
1___2___3___4___5___ |
| 10 |
Embarrassed about
present dental condition |
1___2___3___4___5___ |
| 11 |
Concern about
paying for needed treatment |
1___2___3___4___5___ |
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12 |
Other Concerns you may
have:__________________________________ |
1___2___3___4___5___ |
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2001 -2008 All Rights Reserved
