Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Patient Information Date__________ LOCATION______________________ General Dentist _________________________ Patient’s Name______________________________________________________________________________ Last First Middle Address____________________________________________________________________________________ Street City State Zip Home Phone_________________ Pt’s Work Phone ___________________ Cell Phone____________________ Birth Date ___\___\___ Parents/Guardians _____________________ ______________________ ___________ Mother Father Marital Status Name of School ____________________________ Person responsible for Account - complete any information that is not the same as above or below Name______________________________________________ Social Security #_______________________ Last First Middle Address_________________________________________________________________________________ Street City State Zip Relationship to Patient______________________ Home # _________________ Cell #__________________ Employer_________________________ Occupation ____________________ Work #__________________ Email address_____________________________ The below policy holder's signature authorizes the office of Alpine and Rafetto Orthodontics to affix my name to any and all claims or documents related to any and all orthodontic benefits due me and my dependents through my employment. I authorize payment of orthodontic benefits, otherwise payable to me, directly to the office of Alpine & Rafetto Orthodontics. Dental / Orthodontic Insurance Information (DENTAL ONLY) 1. Policy Holder's Name__________________________Signature________________________________ Policy Holder’s Address________________________________________________________________ Employer______________________________________ Occupation____________________________ Relationship to Patient_____________________ SSN _________________ Birth Date _____\_____\____ Home #__________________ Work # ____________________ Cell #__________________________ ID number on card______________________________ Account # _____________________________ Name of Insurance Company ___________________________________________________________ Telephone Number of Insurance Company _________________________________________________ This BOX for office use only Benefits: Employee: Covered YES NO Spouse: Covered YES NO Age: Ded: Date__________Initial___________ 2. Policy Holder’s Name _________________________ Signature _______________________________ Policy Holder’s Address _______________________________________________________________ Employer ____________________________________Occupation______________________________ Relationship to Patient___________________ SSN___________________ Birth Date _____\_____\____ Home #_____________________ Work #____________________ Cell #________________________ ID number on card_____________________________ Account #_______________________________ Name of Insurance Company____________________________________________________________ Telephone Number of Insurance Company_________________________________________________ This BOX for office use only Benefits: Employee: Covered YES NO Spouse: Covered YES NO Age: Ded: Date__________Initial___________ Who may we thank for referring you to our office? _____________________________________ List family members who have completed treatment or are currently being treated at our office: ________________________________________________________________________________ Concerns that you would like orthodontist to addressed:___________________________________ ________________________________________________________________________________ Patient’s Health Information Patient’s Physician_____________________________________ Phone # ___________________ List medications currently taking: ____________________________________________________ Are there any medical conditions that we should know about? ______________________________ ________________________________________________________________________________ Have you ever had any of the following diseases, medical problems or allergies? (Circle Y or N) Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N Heart Murmur Y N Psychiatric / Learning / Coordination problems Rheumatic Fever Y N Epilepsy / Seizures / Fainting Spells Heart Surgery Y N Diabetes / Tuberculosis (TB) Pacemaker Y N HIV & AIDS Mitral Valve Prolapsed Y N Hemophilia / Abnormal bleeding Kidney problems Y N Cancer / Chemotherapy / Radiation treatment Asthma / Arthritis Y N Artificial bones / Joints Hepatitis Y N Sinus / Breathing problems Aspirin / Codeine Y N Adenoids / Tonsils removed Dental Anesthetics Y N Latex / Rubber Gloves Penicillin / Tetracycline / Erythromycin / Sulfa Meds Are you aware of any other allergies? ______________________________________________ ________________________________________________________________________________ Female teens: Please indicated month and year menses started ______________________________ Have you ever experienced pain, clicking, popping noises in your jaw joint? __________________ Have you ever had an injury to your mouth, teeth or chin? _________________________________ GOOD FAIR POOR Would you say your overall dental health is: I certify that I have read and understand the above questions. To the best of my knowledge, the above questions have been completely and accurately answered. A photocopy of this document may act as an original. _______________________________________ Signature of Responsible Party ______________________ Date Information Updates ____________________________ Initials Date Information Updates ____________________________ Initials Date 6/13