PATIENT INFORMATION

Circle One: Dr/Mr/Mrs/Ms/Miss Sex: M F First: __________________________ Middle: _____________________ Last:___________________

Street: __________________________________City: _________________State: _______ Zip: _____

Home Phone: _________________________ Work Phone: __________________________________

Cell Phone: ___________________________

Email Address: _________________________________ May we contact you by email? Yes No

Social Security Number: _________________________ Patient Date of Birth: ____________________

Emergency Contact: __________________________________ Phone: _________________________

How did you hear about us? Yelp Google Facebook Other:_____________________

Or who may we thank for referring you: ___________________________________________________

Insurance Information Do you have Dental Insurance?(circle) Yes No Do you have Secondary Dental Insurance?(circle) Yes No

Responsible Party (If different from above)

Name of person responsible for account:___________________________________________________

Relationship to patient:_____________________________Insurance Group Number: _______________

Address: __________________________________________________Birthdate: __________________

Social Security:_______________________________Employer:________________________________

Work Phone: __________________________

Primary Insured Secondary Insured

Subscriber Name Subscriber Name

Subscriber SSN Subscriber SSN

Date of Birth Date of Birth

Relationship to Subscriber

🔲 Self 🔲 Spouse🔲 Child

🔲 Other

Relationship to Subscriber

🔲 Self 🔲 Spouse 🔲 Child

🔲 Other

Employer Name Employer Name

Employer Phone Employer Phone

Insurance Company Insurance Company

Insurance Group # Insurance Group #

Insurance Phone # Insurance Phone #

*Please present your insurance card to our patient services representative to be photocopied*

PATIENT HEALTH HISTORY FORM

Patient Name:________________________________ Date:________________________

PATIENT DENTAL HEALTH

Why have you come in to see us today? (e.g: pain, checkup, cosmetic)________________________________________

Last Dental Appointment: ___________________________________

Have you had any problems with past dental treatments? _________________________________________________

Are you nervous about seeing a dentist? 🔲 Yes 🔲 No

How often do you brush? ________________________________ Do you floss? 🔲 Yes 🔲 No How often?________

Y N I clench or grind my teeth during the day or while sleeping. Y N My gums feel tender or swollen.

Y N My gums bleed while brushing while brushing or flossing. Y N I have problems eating.

Y N I’m interested in cosmetic treatment. Y N I have had orthodontics.

Y N I avoid brushing part of my mouth due to pain. Y N I have had a facial or jaw injury.

Y N I’m interesting in (Invisalign / Braces) Y N I want my teeth straight.

Y N I want my teeth whiter Y N I like my smile.

PATIENT MEDICAL HEALTH Do you have or have you had any of the following diseases/conditions?

1.- YES NO Organ Transplant

2.- YES NO Tuberculosis (active/currently)

3.- YES NO Heart Attack If YES Date:_________________

4.- YES NO Heart Surgery (including stents) If YES Date:_________________

5.- YES NO Stroke If YES Date:_________________

6.- YES NO Chemotherapy If YES Date:_________________ 7.- YES NO Pregnant (currently pregnant). If YES Due Date: _____________ 8.- YES NO Artificial /Damaged Heart Valve(s) 9.- YES NO History of Infective Endocarditis 10.- YES NO Congenital Heart Conditions (you were born with it) 11.- YES NO Joint Replacement 12.- YES NO Immune Suppression/HIV/AIDS 13.- YES NO Heart Condition (including pacemaker, defibrillator) . 14.- YES NO Asthma/Lung/Breathing Disorder

15.- YES NO Bleeding Disorder

16.- YES NO Cancer If YES Type: ______________________

17.- YES NO Diabetes If YES Type: _______________________

18.- YES NO Epilepsy/Seizures

19.- YES NO Hepatitis or Liver disease of any kind. If YES Type:________________

20.- YES NO High Blood Pressure

21.- YES NO Kidney/Renal Disease

22.- YES NO Do you use tobacco

23.- YES NO Do you consume alcohol

24.- YES NO Do you take probiotics

25.- YES NO Do you have any disease or condition not listed above?

If YES, please specify:____________________________________

_____________________________________________________

Please explain any YES answers here

Question # _______ Explanation:

____________________________________

____________________________________

_____________________

Question # _______

Explanation:

____________________________________

____________________________________

________________________

Question # _______ Explanation:

____________________________________

____________________________________

________________________

If more space is needed, please use the

last page.

INSTRUCTIONS TO PATIENT: Please answer the following questions as completely and accurately as possible. All Information is CONFIDENTIAL.

YES NO Are you under the care of a physician at the present time or have you been treated by a healthcare provider in the last six months? If YES, please specify:__________________________________________________________________________

YES NO Are you allergic or had any adverse reactions to LATEX, any medicines, drugs, local anesthetics or other substances? If YES, please identify:__________________________________________________________________________

YES NO Are you receiving or have you ever received/taken INTRAVENOUS Bisphosphonates? i.e. Have you taken any of the following drugs INTRAVENOUSLY for the treatment of Osteoporosis or cancer?

Clondronate (Bonefos®, Clasteon®, or Ostac®), Pamidronate (Aredia®), Zolendronic acid (Zometa® or Aclasta®), Neridromate or Reclast®. This list of IV Bisphosphonates should not be considered complete as new drugs are continually being developed.

YES NO Is there anyone in your life (at home, work, neighbor, etc.) harming you in any way? (Your answers are confidential. We are here to help.)

Family Doctor name and phone number:___________________________________________________

Include all prescription and non-prescription (over the counter and recreational) drugs and/or medications you are currently taking, or are prescribed for you that you are not taking for any reason.

I certify that I have read and understand the above. I acknowledge that I have answered these questions accurately and completely. I will not hold Ricardo Peralta DDS Inc responsible for any action taken or not taken because of errors I may have made when completing this form.

SIGNATURE (Parent or Guardian if patient is a minor):________________________________________

DATE: _______________

Name of Drug

Amount/Dose

Reason for Taking

Last Taken

(Day/AM or PM)

How is drug taken?

(Oral, Injected, Smoked/Vaped, Ingested)

Sleep Related Dental Questionnaire Name: _________________________________________________ Age: _______Gender: ________

Height: ______ ____ in. Weight:________ lbs. Blood Pressure: _______ / _______mm Hg

Epworth Sleepiness Scale

How likely are you to feel tired or doze

Assignment of Benefits (If Insured) I hereby assign all dental benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s) to issue payment check(s) directly to Ricardo Peralta DDS Inc. for dental services

AFib Yes 🔲 No 🔲 Thyroid problems Yes 🔲 No 🔲

Heart disease or failure Yes 🔲 No 🔲 Head, neck or jaw pain Yes 🔲 No 🔲

Stroke Yes 🔲 No 🔲 Daytime tiredness Yes 🔲 No 🔲

Weight gain Yes 🔲 No 🔲 Chronic pain Yes 🔲 No 🔲

CPAP use Yes 🔲 No 🔲 Taken a sleep test Yes 🔲 No 🔲

Difficulty staying asleep Yes 🔲 No 🔲 High blood pressure Yes 🔲 No 🔲

Family history of sleep apnea Yes 🔲 No 🔲 Snore Yes 🔲 No 🔲

Type 2 diabetes Yes 🔲 No 🔲 Headaches Yes 🔲 No 🔲

Acid reflux Yes 🔲 No 🔲 Mornings feel great Yes 🔲 No 🔲

Sleep apnea Yes 🔲 No 🔲 Yes 🔲 No 🔲

Situation Chance of Dozing

Sitting and reading No 🔲 Slight 🔲 Moderate 🔲 High 🔲

Watching TV No 🔲 Slight 🔲 Moderate 🔲 High 🔲

Sitting inactive in a public place (e.g a theater or a meeting)

No 🔲 Slight 🔲 Moderate 🔲 High 🔲

As a passenger in a car for a hour without a break No 🔲 Slight 🔲 Moderate 🔲 High 🔲

Lying down to rest in the afternoon when circumstances permit

No 🔲 Slight 🔲 Moderate 🔲 High 🔲

Sitting and talking to someone No 🔲 Slight 🔲 Moderate 🔲 High 🔲

Sitting quietly after lunch without alcohol No 🔲 Slight 🔲 Moderate 🔲 High 🔲

In a car, while stopped for a few minutes in traffic No 🔲 Slight 🔲 Moderate 🔲 High 🔲

rendered to myself and/or my dependent(s) regardless of my insurance benefits, if any. Ricardo Peralta DDS Inc. will provide an estimate of insurance coverage upon request. I understand that Ricardo Peralta DDS Inc. is not responsible for inaccurate estimates. Payment(s) of a dental claim is not guaranteed by any insurance and is based on eligibility and policy coverage at the time a claim is submitted. I understand that I am responsible for any amount not covered by my insurance and I agree to pay any balance amount, within 30 days upon presentation of the appropriate statement.

Financial Responsibility (All) I have requested dental services from Ricardo Peralta DDS Inc. on behalf of myself and/or my dependent(s), and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of treatment. All professional services rendered are charged to the patient and are due at the time of services, unless other arrangements have been made in advance. Necessary forms will be completed to help expedite insurance carrier payments as a courtesy to you. However, you are responsible for all fees, regardless of insurance coverage.

Cancellation Policy We apologize for any inconvenience this notice may cause, but in order to help standardize our appointment schedule and to help open up valuable time for fellow patients we require a 48 hour cancellation notice. If we do not receive a 48 hour cancellation notice you will be charged $60.00

Authorization to release information (If Insured) I hereby authorize Ricardo Peralta DDS Inc. to furnish and/or release any information necessary to insurance carriers concerning my/my dependent(s) dental treatment, to process my insurance claim acquired in the course of my/my dependent(s) examination or treatment, to allow a photocopy of my signature to be used to process my insurance claim(s). This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

In compliance with federal law, I have been given the opportunity to review the Privacy and Materials Fact Data Sheet.

_____________________________________ ________________

Responsible party signature Date

___________________________________________

Print Responsible Party Name/Relationship