DOTHAN COSMETIC DENTISTRY Dr. Geoff Gaunt, D.M.D Patient registration Chart Id: Date: First Name: Last Name: Middle Initial: Address: City State Zip Home Phone: Sex: Male Female Cell Phone: Dob: Age: Work Phone: SSN: Email: Driver Lic: Marital Status: Single Married Widowed Separated Divorced Employment Status: FULL TIME PART TIME RETIRED Prefered Dentist: Student Status: FULLTIME PART TIME Prefered Pharmacy: RESPONSIBLE PARTY (IF SOMEONE OTHER THAN PATIENT) First Name: Last Name: Middle Initial: Address: City State Zip Home Phone: Primary Insurance Holder: Cell Phone: Dob: Age: Work Phone: SSN: Email: Driver Lic: INSURANCE INFORMATION Primary: Secondary: Name Of Insured: Name Of Insured: Relationship: Dob: Relationship: Dob: Insured SSN: Insured SSN: Insurance: Insurance: Policy Number: Policy Number: Address: Address: City: State Zip: City: State Zip:   DOTHAN COSMETIC DENTISTRY Dr. Geoff Gaunt, D.M.D Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you make be taking, could have an important interrelationship with the dentistry you will receive. Please answer the following questions so that we may treat you to the best of our ability. Thank you! Are you under a physician's care now? Yes No If yes Have you ever been hospitalized or had a major operation? Yes No If yes Have you ever had a serious head or neck injury? Yes No If yes Are you taking any medication, pills, or drugs? Yes No If yes Do you take, or have you taken, Phen-Fex or Redux? Yes No If yes Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No If yes Are you on a special diet? Yes No If yes Do you use tobacco? Yes No If yes Do you use controlled substances? Yes No If yes Women: Are you... Nursing? Pregnant/Trying to get pregnant? Taking oral contraceptives? Are you allergic to any of the following? Acrylic Aspirin Codeine Latex Metal Penicillin Sulfa Drugs Local Anesthetics Other: Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above? If yes Comments: To the best of my knowledge, the questions on this form have been correctly answered. I understand that providing incorrect information can be dangerous to my (or the patients) health. It is my responsibility to inform the dental office of any changes in my medical status. Date:   DOTHAN COSMETIC DENTISTRY Dr. Geoff Gaunt, D.M.D Questionnaire Patient Name: Date: Please take the time to answer the following questions for us. This will help us to better understand and address each of your unique concerns. 1. Were you referred to our office? Yes No 2. If so, who may we thank for your referral? 3. When was your last professional cleaning and bywhom? a. Where there X-Rays taken at that time? Yes No 4. How often do you have your teeth cleaned? 5. How often do you floss your teeth? 6. Do you have sensitive teeth? Yes No 7. Do you have a history of gum disease? Yes No a. If so, have you seen a specialist? Yes No 8. How do you feel about dental visits? RELAXED ANXIOUS NEUTURAL 9. Tell us about your habits. Do you....? a. Grind or Clench? Yes No b. Bite your fingernails? Yes No c. Smoke? Yes No If yes, how many per day? d. Use smokeless tobacco? Yes No e. Use a hard toothbrush? Yes No 10. Do you or your partner snore? YOU YOUR PARTNER BOTH 11. Do you feel tired during the day? Yes No 12. Does your bite feel right? Yes No a. If no, please explain 13. Do you wake up with headaches? Yes No 14. Do your jaw joints hurt? Yes No 15. Have you had Orthodontics (braces)? Yes No a. If so, who did them and when were they removed? 16. Do you like the appearance of your teeth? Yes No 17. What about the appearance of your teeth bothers you? Stains Chips or cracks Unattractive: Crowns or Bonding Color Length White or dark spots Spaces Crooked teeth Shape of teeth 18. Would you like your smile to look 10 years younger? Yes No 19. Are you concerned about a receding gumline? Yes No 20. Do you want to have any missing teeth replaced? Yes No 21. Do you have any silver fillings that you would like to have replaced with new white bonded fillings? Yes No 22. Do you have teeth that you believe need porcelain veneers or all-porcelain crowns? Yes No 23. Would you like to learn more about invisible braces? Yes No Please Tell Us more about your dental goals:   DOTHAN COSMETIC DENTISTRY Dr. Geoff Gaunt, D.M.D Acknowledgement of receipt of notice of privacy practices Date I, , have received a copy of Dothan Cosmetic Dentistry NOTICE OF PRIVACY PRACTICES. I acknowledge that I understand the use of my private information for treatment and insurance purposes. I give my consent for Dothan Cosmetic Dentistry to file my information for me Patient Signature: Witness Signature: ___________________________ DOTHAN COSMETIC DENTISTRY Dr. Geoff Gaunt, D.M.D Statement Of Financial Responsibility Assignment of Insurance Benefits I hereby authorize payment directly to Dothan Cosmetic Dentistry of all medical benefits otherwise payable to me or on my behalf for the treatment(s) performed and/or service(s) rendered at Dothan Cosmetic Dentistry. I understand any payment sent directly to me shall then be forwarded to Dothan Cosmetic Dentistry. I understand any unpaid deductibles, co-pays, or co-insurance amounts not payable by my insurance are my responsibility regardless of any pending insurance amounts. These amounts due from me are due on the date of service. This assignment of benefits is valid for insurance companies and programs. Authorization of Release of Information I authorize Dothan Cosmetic Dentistry to release any and all medical information concerning the treatment(s) and/or service(s) performed at Dothan Cosmetic Dentistry as may be required by my insurance company in order to process payment of my claim(s) Charges I understand that standard charges have been established for all services at Dothan Cosmetic Dentistry. I further understand that the fee(s) for my treatment(s) and/or service(s) performed at Dothan Cosmetic Dentistry will be billed to my insurance company. If any additional treatment(s) and/or service(s) are deemed necessary by my physician, and performed today, those treatment(s) and/or service(s) will be billed to my insurance company as well. Credit Policy Dothan Cosmetic Dentistry will file the appropriate claim forms to my insurance carrier. I will be notified when the final action (payment, denial, etc.) by my insurance carrier has been received. I understand that if my account becomes delinquent it will be placed with Prim and Mendheim LLC. Further, I agree to the following terms regarding any outstanding balance that I owe: (1) I will incur interest at the rate of 1&1/2 percent per month (18% per annum); (2) I agree and hereby consent that I will be responsible for reasonable collection costs, attorney's fees, and any court costs that are incurred by Dothan Cosmetic Dentistry in the collection of same, whether such outstanding balance is satisfied prior to, after initiation of a lawsuit, or after a judgment has been issued in a lawsuit; and (3) I agree and hereby consent that any lawsuit and/or legal proceeding surrounding the outstanding balance and debt, and fees and costs thereon, shall be initiated and litigated in the court of appropriate jurisdiction of Houston County, Alabama, and I hereby waive any and all defenses and/or objections to said jurisdiction. I agree that if I have listed a cell phone number as a point of contact that I can be called at that number regarding my balance. Additionally, I agree to waive any and all state and/or federal personal property exemptions, wage exemptions, and/or homestead exemptions of my state of residence and/or state of operation in the event of judgment, levy, and/or garnishment. Further, if I reside in Florida or Georgia I agree to waive my rights to any exemption that would prohibit a wage garnishment should same become necessary to secure payment of any outstanding balance. I, , have read and understand the terms of this policy statement. Date Patient's Signature (Parent or Guardian if Minor) Date Signature of Insured if other than Patient Please enter code above in the field below.