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Please Complete and Return to the Business Office

Insured Person’s Full Name Date of Birth

Social Security Number Relationship to Patient Work Phone

Insurance Company Name Group or Union Name Group or Local Numbers

Employer’s Name Full Address of Employer

Is insured a patient? ❐Yes ❐No

Name: Last First Middle

Address: Street, Apt. or P.O. Box # City State Zip code

Cell Phone: Home Phone: Work Phone:

Age: Yrs. Birth Date: Mo. Day Year Email Address ( ) Male ( ) Female

Social Security No: (if child, parents) Whom may we thank for your referral?

Occupation: Employer: How long employed?

Employer Address & Phone No: Emergency Contact and Phone No:

Person responsible for bill: Age: Relationship to Patient: ( ) Male Social Security No: ( ) Female

Driver’s License No:

Address: Street, Apt. or P.O. Box # City _ State Zip code

Home Phone: Work Phone: Ext. Cell Phone:

Occupation: Employer: Best Time to Call:

Employer Address & Phone No:

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1. Why did you select our practice?

2. Is another member of your family or relative a patient in our practice?4. Person to contact for emergency: Phone:

602 North Winfree St., Dayton, TX 77535 Phone: 936-258-5597

Fax: 936-258-5596www.CardinalDentalGroup.com

FOR ALL PATIENTS I hereby authorize the doctor to perform any and all forms of treatment, medication, and therapy that may be indicated in connection with the dental care of the patient above and further authorize and consent that the doctor chooses and employs such assistance as he or she deems fit. I also understand that previous to treatment, full explanation of the procedure(s) involved will be given by the doctor and/or team. I agree to pay for all services rendered by this office.

Signature of Responsible Party Relationship Date

1. Cash and personal checks are accepted as your treatments are provided.

2. If you have dental insurance, we want you to receive the full benefit of it. Our office team can assist you in completing your insurance forms and verifying the coverage that your particular program provides. We accept assignment of your insurance payment, another service to you. This means that you are responsible for your deductible and the portion the insurance does not cover. Remember, however that you are responsible for the account if the insurance company, for any reason, does not honor their commitment to you and to us.

3. MasterCard, Visa and Discover, American Express

4. For long term or extended payments, we offer a healthcare financing program, which once you are extended a line of credit will allow small monthly payments for the treatment received. Pa

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Please check appropriate box:

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MEDICAL HISTORY

1. Have you been under the care of a medical doctor during the past two years?…………………………………….❐Yes ❐NoIf yes: for what reason? Please provide the name, address, and telephone number of your physician.

2. Have you been a patient in the hospital during the past five years?………………………..………………………..❐Yes ❐No If yes: for what reason?

3. Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin? ❐Yes ❐No If yes, please list: 4. Have you taken any medicine or drugs during the past two years? If yes, please list: ……………………………❐Yes ❐No 5. Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs? ❐Yes ❐No Also, have you taken any of the following: (circle if yes) Fen-Phen Pondimin Redux Other If yes to any of the above, did you have a medical exam for heart issues? …………………………………… .…..❐Yes ❐No 6. Are you allergic to the following? ❐Aspirin ❐Penicillin ❐Codeine ❐Acrylic ❐Metal ❐Latex ❐Sulfa Drugs ❐Local Anesthetics ❐Other 7. Do you use tobacoo?…………………………………….…..…………………………………….….……………………..❐Yes ❐No 8. Do you use controlled substances?…………………………………….…..…………………………………….….……...❐Yes ❐No

9. Are you on a special diet?…………………………………….…..…………………………………….….……..............❐Yes ❐No 10. Check any of the following which apply in either past or present:

11. Do you have any disease, condition or problem not listed? If so, please list………………………………..…...….❐Yes ❐No

12. Women: Are you pregnant or think you could be pregnant? Yes Months No Nursing? ❐Yes ❐No 13. Do you use birth control prescriptions?…………………………………………………………….……………………❐Yes ❐No

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication. Patient / Guardian Signature Date

Print Name DOB



❐ AIDS/HIV Positive❐ Alzheimer’s Disease❐ Anaphylaxis❐ Anemia❐ Angina❐ Arthritis/Gout❐ Artificial Heart Valve❐ Artificial Joint❐ Asthma❐ Blood Disease❐ Blood Transfusion❐ Breathing Problem❐ Bruise Easily❐ Cancer❐ Chemotherapy❐ Chest Pains❐ Cold Sores/Fever Blisters❐ Congenital Heart Disorder❐ Convulsions❐ Cortisone Medicine

❐ Diabetes❐ Drug Addiction❐ Easily Winded❐ Emphysema❐ Epilepsy or Seizures❐ Excessive Bleeding❐ Excessive Thirst❐ Fainting Spells/Dizziness❐ Frequent Cough❐ Frequent Diarrhea❐ Frequent Headaches❐ Genital Herpes❐ Glaucoma ❐ Hay Fever❐ Heart Attack/Failure❐ Heart Murmur❐ Heart Pacemaker❐ Heart Trouble/Disease❐ Hemophilia ❐ Hepatitis A

❐ Hepatitis B or C❐ Herpes❐ High Blood Pressure❐ High Cholesterol❐ Hives or Rash❐ Hypoglycemia❐ Irregular Heartbeat❐ Kidney Problems❐ Leukemia❐ Liver Disease❐ Low Blood Pressure❐ Lung Disease❐ Mitral Valve Prolapse❐ Osteoporosis❐ Pain in Jaw Joints❐ Parathyroid Disease❐ Psychiatric Care❐ Radiation Treatments❐ Recent Weight Loss❐ Renal Dialysis

❐ Rheumatic Fever❐ Rheumatism❐ Scarlet Fever❐ Shingles ❐ Sickle Cell Disease❐ Sinus Trouble ❐ Spinia Bifida❐ Stomach/Intestinal Disease❐ Stroke❐ Swelling of the Limbs❐ Tuberculosis❐ Thyroid Disease❐ Tonsillitis❐ Tumors or Growths❐ Ulcers❐ Venereal Disease❐ Yellow Jaundice

DENTAL HISTORY

1. What is the reason for your visit today?

2. Date of last dental visit Last dental cleaning Last full mouth X-Rays 3. What was done at your last dental visit?

4. Previous Dentist’s NameAddress/State/ZipTelephone

5. How often do you have dental examinations?6. How often do you brush your teeth? How often do you floss? 7. Have you ever used or are currently using topical fluoride? …………………………………………………...❐Yes ❐No8. What other dental aids do you use? (Waterpik, toothpick, etc.)9. Do you have any dental problems now? ..……………………………………………………………………...❐Yes ❐No If yes, please describe.

10. Check any of the following which apply in either past or present:

❐Hot or Cold Sensitivity ❐ Snore or other sleeping disorders❐ Sweets Sensitivity ❐ Use, smoke, chew tobacco❐ Biting or Chewing Sensitivity ❐ Orthodontic treatment❐ Experience bad odors or bad tastes ❐ Oral Surgery❐ Frequent cold sores, blisters or other lesions ❐ Periodontal treatment❐ Bleeding gums ❐ Your teeth ground or bite adjusted❐ Painful gums ❐ Received a bite plate or mouth guard❐ Experienced gum disease ❐ Clicking or popping of jaw❐ Have tooth loss ❐ Pain (joint, ear, side of face)❐ Loose teeth ❐ Difficulty opening / closing mouth❐ Change in your bite ❐ Difficulty chewing on either side of mouth❐ Food catches between your teeth ❐ Head, neck, or shoulder aches❐ Clench or grind teeth while asleep ❐ Sore muscles (neck, shoulder)❐ Clench or grind teeth while awake ❐ A serious injury to the mouth or head?❐ Bite lips or cheek regularly If so, please describe, including cause❐ Hold foreign objects with teeth (i.e. pencil)❐ Mouth breathe while awake or asleep ❐ Experience tired jaws, especially in the morning

11. Are you satisfied with your teeth’s appearance?…………… …………………………………………….……......….❐Yes ❐No12. Would you like to keep all of your teeth all of your life? ………………………………………………...….……...….❐Yes ❐No13. Do you feel nervous about dental treatment? …… …………………………………………………...…….……...….❐Yes ❐No

If so, what is your biggest concern? 14. Have you ever had an upsetting dental experience? …………………………………………………….………...….❐Yes ❐No

Please describe. 15. Have you ever been told to take a pre-medication prior to dental treatment? ………………………….…….....….❐Yes ❐No16. Is there anything else you would like us to know? Please describe.



Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Cardinal Dental Group. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Cardinal Dental Group reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

ADDITIONAL DISCLOSURE AUTHORIZATION

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.) Spouse only YES NO

OR Any Member of my immediate family: (Spouse, Children, Children's Spouses) YES NO Any Member of my extended family: (Parents, Grandchildren) YES NO Other: YES NO

Name of patient (please print):

Patient signature:

Patient's personal representative: (Please Print):

Personal Representative's signature:

Representative's Telephone Number: Date:

OFFICE USE ONLY BELOW THIS LINE

Acknowledgement Not Obtained NO Date Statement Provided:_______

Provided Prior to Treatment? YES

Needed more time to review Statement Reason for not obtaining patient signature

Wanted to consult another person before signing

Physically unable to sign

No reason offered

Other:





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SMILE ANALYSIS



Your smile affects your self-esteem and can greatly influence the ways you interact with others. Many people hold back from laughing or smiling because they are uncomfortable with their smiles. The following questions are designed to honestly appraise your smile. Go to a mirror, smile as wide as you can, and ask yourself the following questions:

Are any of my teeth yellow, stained, or somewhat discolored? ................................................................................❐Yes ❐No

Would I like my teeth to be whiter? ............................................................................................................................❐Yes ❐No

Do I have any gaps or spaces between my teeth? ....................................................................................................❐Yes ❐No

Are any of my teeth turned, crooked, or uneven? ....................................................................................................❐Yes ❐No

Am I missing any teeth? ............................................................................................................................................❐Yes ❐No

Do I see any pitting or defects on the surfaces of my teeth? ....................................................................................❐Yes ❐No

Are the edges of any teeth worn down, chipped, or uneven? ....................................................................................❐Yes ❐No

Do any of my teeth appear too small, short, large, or long? ....................................................................................❐Yes ❐No

Do I have any prior dental work that appears unnatural? ........................................................................................❐Yes ❐No

Do I have any crowns or bridges that appear dark at the edge of my gums? ............................................................❐Yes ❐No

Do I have any gray, black, or silver (mercury) fillings in my teeth? ............................................................................❐Yes ❐No

Do I have a "gummy" smile (too much of my gums show when smiling)? ................................................................❐Yes ❐No

Are my gums red, sore, puffy, bleeding, or receded? ................................................................................................❐Yes ❐No

Does the appearance of my smile inhibit me from laughing or smiling? ....................................................................❐Yes ❐No

When being photographed, do I smile with my lips closed instead of flashing a full smile? ....................................❐Yes ❐No

Am I self-conscious about my teeth or smile?............................................................................................................❐Yes ❐No

Would I like to change anything about the appearance of my teeth or smile? ........................................................❐Yes ❐No



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