Medical History Form

First Name

Middle Name

Last Name

Birthday

Email Address

Patient Home Phone

Patient Cell Phone

Healthcard Number

Patient Home Address

Patient Biling Address

Region/State/Province

City

Postal / Zip Code

Country

Company

Position

Employment /School /University Name

Name Of Family Physician

Physician Phone Number

Are You Currently Suffering From A Medical Condition, Illness, Or Injury?

YesNo

Have You Been Hospitalized In The Last 12 Months?

YesNo

If You Answered Yes To Any Question, Please Elaborate

When Did You Last Have Dental X-rays Taken?

When Was Your Last Dental Visit?

How Often Do You Brush Your Teeth?

How Often Do You Floss?

Have You Been Seeing A Dentist Regularly?

YesNoN/A

Do Any Of Your Teeth Ache?

YesNoN/A

Have You Ever Been Advised To Take Antibiotics Before Dental Appointments?

YesNoN/A

Do Your Gums Bleed When You Brush?

YesNoN/A

Do You Have Any Pain When You Chew?

YesNoN/A

Do You Feel That You Have Bad Breath?

YesNoN/A

Have You Ever Been In A Vehicle Accident Or Experienced Any Trauma To Your Jaw?

YesNoN/A

Have You Ever Had Any Implant Surgery?

YesNoN/A

If You Answered Yes To The Last Question, Who Performed The Surgery And When Was It Done?

Date

Are You Being Followed-up By A Dental Specialist?

Do You Have Any Problems With Your Jaw Joint (Pain, Sounds, Limited Opening, Locking, Popping)?

Is There Anything About The Appearance Of Your Teeth You Would Like To Change?

Please List Anything Not Mentioned Above Regarding Your Past Dental History:

If You Chose Other Please Elaborate

Are You Covered Under Any Dental Insurance Policy?

YesNo

Policy #

ID #

Insurance Company Name

APPOINTMENT POLICY When you make an appointment with our office, we consider this a mutual commitment and reserve appropriate facilities and staff exclusively for you. Our office policy states that patients must give us 1 business day or 24 hours notice if they cannot keep an appointment. Appointment changes with less than 1 days notice are subject to a service fee based on the number of staff members and the amount of time that was reserved for you. FINANCIAL POLICY Payment in full is due the day of treatment, or on upon the start of major treatment. Should a patient have dental insurance with assignment to Dr. SANA KHAN, the estimated patient portion will be the amount due. Payment Options 1. For your convenience we accept Cash, Debit, Visa, MasterCard. 2. We also offer short-term financing options but interest charges will apply. All arrangements must be made in advance and are subject to an approval process. For Patients with Dental Insurance Dental insurance plans often pay less than the actual fee for service. Therefore the patient or Guarantor is the responsible party for all dental services provided. Dental insurance in most cases is a benefit with limitations and should not be expected to take care of all costs. You are ultimately responsible for all costs incurred regardless of what your dental insurance covers! Finance Charge and Fees • Balances in excess of 45 days are subject to a finance charge of 2% per month (24% per annum). • Returned checks are subject to a $25 accounting fee. AUTHORIZATION AND CONSENT General Consent to Treatment I agree and consent to a dental examination by Dr. SANA KHAN or an Associate of O'Connor Dentistry. I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatments performed. Release of Information I authorize O'Connor Dentistry to release any information regarding my dental/medical history, diagnosis or treatment to third party payors and/or other health professionals. Assignment of Insurance Benefits I authorize and request my insurance company to pay my benefits directly to Dr. SANA KHAN and Associates. I understand and will comply with office Appointment Policy. I understand and will comply with the office Financial Policy. I understand and agree to the General Consent to Treatment. I authorize the Release of Information. I authorize the Assignment of Insurance Benefits.

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