Mill Dam Dental Care
 Dr. Jeffrey R. Leidy
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 _______
Employer______________________________________ Occupation___________________________________
Home Phone # ______________  Work Phone # ______________ Cell Phone#____________

Nickname_____________________________ Email Address__________________________________________
Marital Status: ____Single  ____Married ____Separated ____Divorced ____Child ____Other
PCP Name (Medical Doctor) __________________________________ PCP Phone #________________________

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 diseases?
__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 deemed necessary and I accept the risk and complications associated with such procedures. 

I authorize the release and use of dental records gathered by his office as they deem necessary, including study models, photographs, and radiographs. I also authorize the release of information necessary for filing 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 all 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 of the treatment. For value received, I guarantee the payment terms as set forth above

GUARANTOR SIGNATURE ______________________________________           DATE: _____________________