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GREENEVILLE DENTAL ASSOCIATES, P.C.
Patient Information
NAME _________________________________________________________________________________________________________________
FIRST
MI
LAST
ADDRESS:______________________________________________ CITY: ____________________________STATE/ZIP:____________________
HOME PHONE: _________________________________________ CELL PHONE: ____________________ SS # ________________________
BIRTH DATE: ______________________ EMAIL: ______________________________ MAY WE CONTACT YOU BY TEXT?
Check Appropriate Box: c Single
c Married
c Divorced
c Widowed c Separated
c MALE
c YES c NO
c FEMALE
EMPLOYED BY: _______________________________________________________________ WORK PHONE: __________________________
SPOUSE NAME: ______________________________________________________________ BIRTHDATE: _____________________________
SPOUSE EMPLOYED BY: _______________________________________________________WORK PHONE: __________________________
PERSON TO CONTACT IN CASE OF EMERGENCY: ________________________________PHONE: _________________________________
Responsible Party Information c Check box if same as above
NAME OF PERSON RESPONSIBLE FOR THIS ACCOUNT: __________________________________ RELATIONSHIP: _________________
ADDRESS: _____________________________________________________________________________________________________________
HOME PHONE: ____________________________________________________ CELL PHONE: _______________________________________
EMPLOYED BY: ____________________________________________________ WORK PHONE: ______________________________________
ACKNOWLEDGEMENT OF RECEIPT
OF NOTICE OF PRIVACY PRACTICES
* YOU MAY REFUSE TO SIGN ACKNOWLEDGEMENT*
I, ___________________________________________________________________________ , have received a
copy of this office’s Notice of Privacy Practices.
I authorize this office to leave messages on my answering machine or with a family member.
I authorize this office the use of mail reminders. I authorize family members to drop off and pick things
up on my behalf. I authorize the release of information (including x-rays) to other doctors/dentist by
my request or on behalf of myself. It is understood that if you bring a friend or family member into our
facility or ask us to call them, that you agree that we may share your personal information with them.
We require written notification if you request that we treat your information in a manner not listed
above or in our privacy policy.
_____________________________________________________________________________________________
SignatureDate
___________________________________________________________________________
FOR OFFICE USE ONLY
___________________________________________________________________________
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:
c Individual refused to sign
c Communications barriers prohibited obtaining the acknowledgement.
c Other (Please specify)
_________________________________________________________________ .
Medications and Allergies
Do you have any Allergies to:
c Penicillin
c Local Anesthetics
c Metals (Earrings)
c Acrylic
c Latex
c Foods
Please list any other: _______________________________________________________________________________________________
Please list all current medications: ___________________________________________________________________________________
__________________________________________________________________________________________________________________
Have you been advised by your physician to take any type of pre-medication before dental treatment due to a pre-existing
medical condition?
c Yes
c No
Is there any other information about your health which should be known?
c Yes
c 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 Greeneville Dental
Associates, P.C. of any changes in medical status.
__________________________________________________________________________________________________________________
Signature of Patient, Parent or Guardian
Date
Dental Insurance Information c Check box if NO insurance
NAME OF INSURED: ___________________________________________________________ RELATIONSHIP: __________________________
SS# OF INSURED: _______________________________________________ BIRTHDATE OF INSURED:_____________________________
EMPLOYED BY: ___________________________________________________ WORK PHONE: ______________________________________
INSURANCE COMPANY: __________________________________________ GROUP#: ___________________________________________
INSURANCE COMPANY ADDRESS: _______________________________________________________________________________________
________________________________________________________________________________________________________________________
Do You Have Additional Dental Insurance
c No
c Yes
IF YES, COMPLETE THE FOLLOWING
_______________________________________________________________________________________________________________________________________
NAME OF INSURED: ___________________________________________________________ RELATIONSHIP: __________________________
SS# OF INSURED: _______________________________________________ BIRTHDATE OF INSURED:_____________________________
EMPLOYED BY: ___________________________________________________ WORK PHONE: ______________________________________
INSURANCE COMPANY: __________________________________________ GROUP#: ___________________________________________
INSURANCE COMPANY ADDRESS: _______________________________________________________________________________________
FORM 174860
R/05/11
ITEM 40684
Patterson Office Supplies 800.637.1140
MEDICAL HISTORY
Name: ____________________________________________
Birthdate: _____________________
* May Need Pre-Med
Please check all that apply
N
May not use N2O
Hep B/Hep C N
Tuberculosis (TB) N
Macrocytic Anemia N
Immune Diseases N
Respiratory Diseases N
Middle Ear Infection N
Pregnancy N
Claustrophobia N
Psychiatric Care
Drug Addiction
Hemophilia (Bleeding Disorders)
Herpes
Cold Sores/Fever Blisters
HPV
Pacemaker
Fibromyalgia
Seizures - Do you take Tegretol (Carbamazepine)- No E-mycin
Joint Replacement (Past 2 years or complications)
HIV or AIDS
Organ Transplant
Rheumatoid Arthritis
Kidney Disease (Dialysis)
Diabetes
Liver Disease (Cirrhosis)
Inflammatory Bowel Disease (Crohn’s or Ulcerative Colitis)
Chronic Obstructive Pulmonary Disease (COPD) N
Cancer or History of Cancer/Leukemia/Non-Hodgkin Lymphomas
Cancer Treatment (Radiation/Chemotherapy)
Lupus
Artificial Heart Valve *
Cardiac Stent (Past 12 Months)
Endocarditis In Past *
Breast Implants
Congenital Heart Condition *
Lasix Eye Surgery (Past 2 Months) N
Congestive Heart Failure N
Heart Attack/Heart Failure
Chronic Bronchitis N
Emphysema N
Bronchiectasis N
Trigeminal Neuralgia - Do you take Tegretol (Carbamazepine) - No E-mycin
Chronic Asthma - Do you take Theophylline- No E-mycin N
Chronic Bronchitis- Do you take Theophylline- No E-mycin N
Sjogren’s Syndrome
Sickle Cell Disease
Stroke
Are you taking or have you ever taken any of the following?
Phen-Fen or Redux *
Illegal Substances
Controlled Substances
Chewing Tobacco
Cigarettes
Bisphosphonates (bone strengthening drugs)
Skelid (Tiludronate)
Zometa (Zoledronic Acid)
Boniva (Ibandronate)
Aredia (Pamidronate)
Ostac (Clodronate)
Fosamax (Alendronate)
Actonel (Risedronate)
Didronel(Etidronate)
Reclast (Zoledronic Acid)
Blood Thinners / Antiplatelet Drugs
Aspirin
Ticlopidine
Plavix (Clopidogrel)
Effient (Prasugrel)
Dipyridamote (Persantine)
Ticlid (Ticlopidine HCI)
Aggrenox
Pletal (Cilostazol)
FORM 184140
R/05/11
ITEM 40684
Steroids
Triazolam (Halcion) - No E-mycin
Monoamine Oxidase Inhibitors - No EPI
Tricyclic Antidepressants - No EPI
Anticoagulants
Heparin
Warfarin (Coumadin)
Pradaxa (Dabigatran Etexilate)
Phenindione
Beta Blockers
Propranolol (Inderal)
Penbutolol (Levatol)
Alprenolol (Gubernal)
Pindolol (Visken)
Bucindolol
Sotalol (Betapace)
Timolol (Betimol)
Levobunolol (Betagan)
Nadolol (Corgard)
Labetalol (Normodyne)
Celiprolol (Cardem)
Metipranolol (Optipranolol)
Patterson Office Supplies 800.637.1140
FINANCIAL AGREEMENT
Payment in full is due to Provider when services are rendered. I accept full financial responsibility for
all charges and fees incurred related to any and all services provided. I acknowledge Provider’s right
and hereby grant Provider permission to charge all fees accrued for services rendered to my Approved
Finance Option without receipt of any additional permission or documentation from me. In the event of
default of payment on this account or any future accounts I may have, I agree to pay any interest
accrued and any legal or court related costs and expenses, including reasonable attorney fees, incurred
by Provider related to Provider’s exercise of collection rights or other legal remedies.
________________________________
DateSignature
APPROVED FINANCE OPTION
Please indicate choice of payment: (circle one)
Cash
Check
American Express
Money Order
Discover
Visa
MasterCard
Care Credit
REGARDING DENTAL INSURANCE (please give receptionist your card to photocopy)
We are happy to help you file your claims. We may estimate the cost of treatment and benefits, but it is
not a guarantee. Your treatment will be determined by your dental needs and your general health, not by
your dental benefit plan. We require that you pay your estimated portion plus the deductible on the day
you receive treatment. I, the undersigned, have dental insurance, and assign all the benefits of
services directly to Greeneville Dental Associates, P.C. I authorize the release of necessary information,
and use of this signature on my insurance submissions.
________________________________
DateSignature
MINOR/CHILD CONSENT
I, the legal parent/guardian of _____________________ , request and authorize the dental staff to
perform necessary dental services for my child, including but not limited to x-rays, local anesthetics and
treatment advised by the doctors. If a legal guardian is not present for the visit, I authorize the dentist to
make decisions on my behalf. By way of example, but not limited to: changes in the treatment plan, the
use of nitrous oxide and/or the type of restoration. (Please discuss preferences beforehand if you are
planning on being absent for the visit)
________________________________
DateSignature
BROKEN/MISSED APPOINTMENTS
I understand a fee will be charged for appointments cancelled with less than 24 hours notice.
________________________________
DateSignature