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Mill Dam Dental Care
Dr. Jeffrey R. Leidy and Dr. Michael E. Edenfield
1301 First Colonial Road, Virginia Beach, VA 23454
Telephone: 757-463-1500 www.milldamdental.com
Facsimile: 757-463-8728
----------------------------PERSONAL
HISTORY----------------------------
Patient Name______________________________ Birth Date____________________
SS#__________ |
Street Address _______________________________________________________________
City _______________
State ____________ Zip _______
Home Phone # ______________ Work Phone #
______________ Cell Phone#____________
|
Email
Address________________________________________________________________
Marital Status: ____Single ____Married ____Separated ____Divorced
____Child ____Other |
|
|
| Person responsible for
account__________________________ Relationship to
patient_________________ |
| Address [if different from
above]______________________________________________________________ |
| Home Phone # ______________ Work
Phone # ______________ Cell Phone#____________
Place of Employment___________________________________
Occupation_______________________
Emergency contact______________________
Phone#_____________ Relationship to patient___________
|
| Agency responsible for
account_________________________________________________________
Address____________________________________________________________________________
Contact
person_______________________________________________________________________
Contact person phone number(s)_________________________________________________________
|
| Do you have dental
insurance? ____Yes
____No
Insurance company
name______________________________________________________________
Subscriber name________________ Birth
date________________ ID#________________________
Group name___________________
Group#_______________________ Phone#________________
|
| What is the reason for your
visit?________________________________________________________
___________________________________________________________________________________
Are you in pain now?____ Date of last dental
visit_________________________________________
Is there anything about your smile that you would like to
change?_____________________________
____________________________________________________________________________________
|
| What do you want your teeth to look
like in 20 years?________________________________________
____________________________________________________________________________________
Does dental treatment make you
nervous?_________________________________________________
|
----------------------------HEALTH
HISTORY----------------------------
| Do you now have, or have you had, any of the
following conditions or disease? |
| __Rheumatic Fever |
__Heart murmur |
__Congenital Heart Disease |
__Heart Surgery |
| __Artificial Joints |
__Heart Attack |
__Pacemaker |
__Hemophilia |
| __Hepatitis |
__Radiation |
__Cancer |
__AIDS / HIV |
| __Venereal Disease |
__Diabetes |
__High Blood pressure |
__Pregnant Now |
| __Artificial
Heart Valve |
__Chemical Dependency |
__Used Fen-Phen |
__Smoke |
| Other
_____________________________________________________________________________________ |
| Are you allergic to any medications?
__No __Yes (if yes, please list)__________________________
____________________________________________________________________________________
Please list any and all medications you are now taking and
why you are taking them.
____________________________________________________________________________________
|
To the best of my knowledge, all of the preceding answers are true and correct.
I also agree to notify the office immediately of any changes in the above
information.
I hereby apply for treatment by the above dentist, their associates and/or assistants. Treatment may include x-rays, injections and/or such other
office procedures they deem necessary and I accept the risk and complications which may be associated with such procedures.
I authorize the release and use of dental records gathered by this office as
deem necessary, including study models, photographs, and radiographs. I also
authorize the release of information necessary for the filling of any insurance;
and direct payment s to this office for any amounts due on my claim under the above stated policies or any
other policy that I may ask to be filed. I have been given a notice of privacy
practices for this office and agree to all information contained within.
I understand that a parent or adult guardian must accompany
my minor child and stay in the office until their dental treatment is completed.
I agree to be
financially responsible for the cost of services rendered to the patient by this
office, and , I understand that if payment is not made when due, I agree to pay
interest on the balance at 1.5 % monthly (18% annually). In the event legal
action results in this going to court, I agree to pay attorney fees equal to 40
% of the total amount due, plus all allowable court costs. I agree to pay $25.00
for any returned checks, in addition to the other terms set forth in the above
paragraphs.
I am aware that I am responsible for payment for all
services rendered if there is an insurance dispute, refusal to pay, or, if
payment is not received from my insurance company within 45 days for treatment.
For value received, I guarantee the payment terms as set forth above
GUARANTOR SIGNATURE ___________________________ DATE: ________________
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