Patient or Guardian signature:_________________________________ Date: _______________

DENTAL PATIENT HEALTH HISTORY

Patient name_____________________________ Date of birth_______________ Height_____ Weight _____

What is your reason for seeking dental treatment? ______________________________________________

If female, are you pregnant? ____, nursing? _____, taking contraceptives? ______

If patient is under 12, what is your source of water? municipal (what town? _____________) well bottled

Who is your Primary Care Provider (PCP)? ______________________________________________________

Please check box next to any health conditions that you have, or have had, and write in details. ☐High blood pressure______________________ ☐Heart issues: heart attack, coronary artery disease, endocarditis, heart murmur/defect, pacemaker, artificial heart valves, surgery, other: _______________________________________________________________________ ☐High cholesterol ☐Current or past history of alcoholism, drug addiction, recreational drug use _____________________ ☐Breathing issues: asthma, COPD, emphysema, chronic bronchitis, other: _______________________ ☐Tuberculosis or positive TB skin test __________________________________________________ ☐Digestive issues: GERD/reflux, Crohn’s disease, IBS, ulcers, surgery__________________________ ☐Stroke. If yes, when? _______________________________________________________________ ☐Immune issues: HIV/ AIDS, auto-immune disorders, other: ________________________________ ☐Liver issues: hepatitis A, B, C, D, E, cirrhosis, fatty liver disease, other: ________________________ ☐Cold sores (Herpes Simplex I) ☐Issue with blood/bleeding/clotting: hemophilia, anemia, factor V leiden, other: __________________

☐ADHD/ADD ☐Thyroid problem___________________________________________________________________ ☐Cancer or tumor (current or past) ______________________________________________________ ☐Diabetes (type I, type II). If yes, what was your last HbA1c score? ________ When was it done? __________ ☐Neurological problems: epilepsy/seizures, neuralgia, other: ___________________________________ ☐Mental health issues: anxiety, depression, bi-polar disorder, schizophrenia, other: ___________________ ☐Kidney problems: kidney failure, stones, other:_______________________________________________ ☐Taken bisphosphonates (Ex. Boniva, Foxamax, Actonel, Atelvia, Reclast etc.) ☐Disability (physical or mental that may require accommodation) _________________________________ ☐Sleep apnea or snoring ☐Artificial Joints ☐Dry mouth Any medical issues not addressed above? _______________________________________________________

Please list all medications you take, including dosage, and any recreational drugs that you take:_______________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please list any medication to which you have had an allergy or adverse reaction and describe reaction (hives, anaphylaxis, GI upset, other :)____________________________________________________________________

Do you use tobacco? ______ If yes, how much? ___________________ If yes, how motivated are you to quit? (please circle) low motivation 1 2 3 4 5 6 7 8 9 10 high motivation Do you drink alcohol? ______ If yes, about how many drinks per week? _____ Do you drink any of these regularly (please circle): fruit juice soda energy drinks coffee or tea with sugar

What is your daily oral hygiene routine? ____________________________________________________

GENERAL DENTAL INFORMED CONSENT TO TREATMENT

I consent to be a patient at Greater Seacoast Community Health Dental Center and agree to a radiographic and clinical examination. I also understand and consent to the following:

1. I will accurately inform the dentist of my medical history including any medications and recreational drugs that I am taking and allergies that I have. I understand that some medications can cause harmful reactions with dental anesthetics, analgesic, antibiotics or other medications.

2. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), restorative dentistry, oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges and dentures), implant dentistry, temporomandibular disorder treatment, oral pathology, pediatric dentistry and radiography. I acknowledge the dentists and their associates will make every effort to explain the nature and purpose of proposed procedures and alternative options, but it is the patient’s responsibility to ask questions and elect for treatment.

3. I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination.

4. I understand that there may be complications resulting from the use of dental instruments, drugs, sedation, medicines, analgesics, anesthetics and injections that include, but are not limited to: swelling, sensitivity, bleeding , pain orinfection;numbness and tingling sensation in the lip, tongue, chin, gums, cheeks, and teeth (which is transient but may, infrequently, be permanent; reaction to injections;changes in occlusion;jaw muscle cramps and spasms;temporomandibular (jaw) difficulty; referred pain to ear, neck, and head;nausea, vomiting , allergic reactions;delayed healing; and treatment failure. The risks of complications from medications used/prescribed with general dental treatment include, but are not limited to, drowsiness, lack of awareness and coordination, nauseaallergic reasons, etc. (which may be influenced by the use of alcohol, tranquilizers, sedatives or other drugs).

5. In the event that a patient requests only a specific problem be addressed (i.e.: broken tooth, pain in one area, etc.) this is considered a problem focused evaluation. X-rays will be taken in this specific area only, and a complete comprehensive exam will not be done. The dentist cannot diagnose problems in other areas of the mouth. Any future treatment of other areas will require additional x-rays and a complete exam. I understand that I will not be considered a patient of record unless this examination is completed.

6. General dentists perform the majority of all dental treatment. However, I understand that Goodwin Community Health desires that all patients should be aware that specialty fields exist in dentistry, particularly in the fields of oral surgery, orthodontics, periodontics, pediatric dentistry and endodontics. In some cases Goodwin Community Health Dental Center may have to refer certain procedures out to a specialist.

7. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.

I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I am signing below that I have read and understood this form.

Printed name of patient: __________________________________ Patient’s date of birth: ___________

Patient or Guardian signature: _________________________________________ Date:_______________

DENTAL BILLING AND FINANCIAL RESPONSIBILITY

Patients are financially responsible for services provided by our office. Greater Seacoast participates with a number of insurance companies and will bill to all insurances.

For your convenience, our office will try to verify your insurance benefits for you. However, ultimately it is the patient’s responsibility to determine benefit and authorization information with your insurance company before services are provided. Please note that verification of benefits is not a guarantee of payment. Your insurance company makes the final determination.

Patients are fully responsible for payment for services not covered by their insurance.

Greater Seacoast strongly recommends that you have us submit a pre-treatment estimate to your insurance company before services are provided. Without this, we can only estimate your portion of the visit. Due to insurance companies’ limitations on frequency of services, waiting periods and maximum allowable charges, there is a chance your services may not be covered if a pre-treatment estimate is not submitted before services are rendered.

Please sign below that you have read and understand the above statement.

Date:_______________

Printed name of patient: ____________________________________________

Patient’s date of birth: _______________

Patient or Guardian signature: _________________________________________

I have read and understand the information about scheduling and keeping dental appointments:

Patient name (printed): ________________________________ Date of birth: __________

Patient/guardian signature: _____________________________ Date: _________________

Arriving on Time for Appointments

Our dental schedule is

based on the amount

of time needed to

complete dental

examinations,

treatments and

procedures, including

oral surgery. When patients arrive late for an

appointment, it becomes challenging for us to

offer everyone high-quality, safe and efficient

care.

Please arrive 15 minutes before your

scheduled appointment time. This allows us to

complete any paperwork needed and have you

ready for your appointment time with your dental

provider.

Giving Enough Notice if You Need to Cancel or

Reschedule

We understand that things come up

unexpectedly. If you need to cancel, please let

us know as soon as you know that you cannot

come to your appointment. We ask that you call

at least 4 hours ahead of time if at all possible.

This may give us time to fill your time slot with

another patient waiting for care.

What happens if ...

… I arrive late for my appointment?

You may be asked to reschedule to a

different day if you are more than 10 minutes

late (including time needed to check in and

fill out your paperwork).

If you are having an acute dental problem, a

dental provider will decide if you need to be

seen or if you can safely reschedule to

another day.

… I miss my appointment, or cancel with less

than 4 hours’ notice?

If you miss two appointments in 12 months,

we will no longer schedule your

appointments in advance

You may call in the morning of the day you

would like to come in to see if a provider is

available to see you that day.

… I am a new patient and miss my first

appointment?

We will not be able to reschedule your

appointment to establish care for six months.

Things to Know

About Your Dental

Appointments

Our Commitment to You

Greater Seacoast Community

Health tries to meet the needs

of all our patients. These dental-

appointment policies help us

provide high-quality care for

you and all our patients.