Download Guest Information

~Dr.Jon~
Jonathan Vongschanphen, DDS, LVIF
Health History
So we can ensure we are looking after your need, please review and complete the following
questionnaire:
(Mr/Mrs/Ms/Dr) First Name:
Last Name:
Date of birth:
Address:
Social Security:
Zip code:
Home phone:
Work Phone:
Mobile:
Email:
Occupation:
Name of person responsible for fees, if not
self:
Address:
What name would you like to go by? ______________________________________________________
How do you prefer us to contact you (or any combination)? O Phone
O Text
O Email
How did you hear about us? ______________________________________________________________
Purpose of visit: __________________________________________________________________________
Is another member of your family a patient at our office: O Yes O No
Have you had any of the following?
Heart Problems
Blood pressure
Artificial joints
Circulatory problems
Radiation treatment
Excessive bleeding
Excessive bruising
Ulcers (stomach)
Sinus Trouble
Tumor history
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
Allergies to anesthetics
Allergies to penicillin
Allergies to medication
Allergies to latex
Anemia or other blood
disorders
Diabetes
Asthma
Hepatitis A B C D E
Liver or Kidney problems
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
O Yes
Are you currently taking any medications? O Yes O No
If ‘yes’, please list: ________________________________________________________________________
~Dr.Jon~
Jonathan Vongschanphen, DDS, LVIF
Have you had any of the following?
Does your jaw click or hurt?
O Yes
Do you smoke?
O Yes
Do you feel you grind your teeth?
O Yes
Have you ever had braces?
O Yes
Do you wear a night guard?
O Yes
Have you ever had gum disease?
O Yes
Have you ever had your bite adjusted?
O Yes
Do you bite your lips or cheeks often?
O Yes
Do you think you have occasional
bad breath?
O Yes
Do your gums ever bleed when you
brush your teeth?
O Yes
Do you experience sensitivity with
hot/cold?
O Yes
Does floss ever tear between your
teeth?
O Yes
Does food get jammed between your
teeth?
O Yes
Do your teeth ever hurt when you bite? O Yes
Do you ever get headaches?
O Yes
Do you have difficulty chewing?
O Yes
Other notes _________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Name of your physician: _____________________________________________________________________________
Phone: _________________________________________ Fax: ______________________________________________
Are you pregnant? O Yes. If yes, what is the due date? ________________________________________________
How long since your last dental appointment? _______________________________________________________
How often do you have dental examinations? ________________________________________________________
Previous dental x-rays taken:
O Less than a year
O Longer than a year
Consent for Treatment
I hereby authorize the doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids
deemed appropriate by the doctor to make a thorough diagnosis. Upon such diagnosis, I authorize the doctor to perform
all mutually agreed treatment upon me and to employ such assistance as required to provide proper care. I agree to the
use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies
certain risks. I understand I can ask for a complete recital of any possible complications. I agree to be responsible for
payment of all services rendered on my behalf and on behalf of my dependents. I understand payment is due at the time of
service unless other arrangements have been made. I understand the above information is necessary to provide me with
dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further
information be needed, you have my permission to ask the respective health care provider who may release such
information to you. I will notify the doctor or appropriate staff member of any change in my health or medication.
I authorize that this data may be reviewed by team members of Lone Tree Dental.
Patient Signature: _________________________________ Date: _____________________________________
Parent/responsible party’s signature: ___________________________________________________________
Relationship to patient: ________________________________________________________________________
~Dr.Jon~
Jonathan Vongschanphen, DDS, LVIF
Employment Information
The following is for:
the patient
the person responsible for payment
Employer Name:
Occupation:
Address:
Street
City
State
Zip Code
Insurance Benefit Information
Primary:
Name of Insured: _______________________________________________ is insured a patient?
Last
First
Yes
No
MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Insured's Address:
Street
City
State
Zip Code
City
State
Zip Code
Insured's Employer Name:
Address:
Street
Patient's relationship to insured:
Self
Spouse
Child
Other________________________________
Insurance Plan Name and Address:
__________________________________________________________________
Secondary (if applicable):
Name of Insured: _______________________________________________ is insured a guest?
Last
First
Yes
No
MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Insured's Address:
Street
City
State
Zip Code
City
State
Zip Code
Insured's Employer Name:
Address:
Street
Patient's relationship to insured:
Insurance Plan Name and Address:
Self
Spouse
Child
Other_________________________________