Greenevilledental.com

GREENEVILLE DENTAL ASSOCIATES, P.C.
Patient Information
NAME _________________________________________________________________________________________________________________
FIRST
ADDRESS:______________________________________________ CITY: ____________________________STATE/ZIP:____________________ HOME PHONE: _________________________________________ CELL PHONE: ____________________ SS # ________________________ BIRTH DATE: ______________________ EMAIL: ______________________________ MAY WE CONTACT YOU BY TEXT? c YES c NO Check Appropriate Box: c Single c Married c Divorced c Widowed c Separated c MALE c FEMALE EMPLOYED BY: _______________________________________________________________ WORK PHONE: __________________________ SPOUSE NAME: ______________________________________________________________ BIRTHDATE: _____________________________ SPOUSE EMPLOYED BY: _______________________________________________________ WORK PHONE: __________________________ PERSON TO CONTACT IN CASE OF EMERGENCY: ________________________________ PHONE: _________________________________ Responsible Party Information c Check box if same as above
NAME OF PERSON RESPONSIBLE FOR THIS ACCOUNT: __________________________________ RELATIONSHIP: _________________
ADDRESS: _____________________________________________________________________________________________________________ HOME PHONE: ____________________________________________________ CELL PHONE: _______________________________________ EMPLOYED BY: ____________________________________________________ WORK PHONE: ______________________________________ * YOU MAY REFUSE TO SIGN ACKNOWLEDGEMENT* I, ___________________________________________________________________________ , have received a
copy of this office’s Notice of Privacy Practices.
I authorize this office to leave messages on my answering machine or with a family member.
I authorize this office the use of mail reminders. I authorize family members to drop off and pick thingsup on my behalf. I authorize the release of information (including x-rays) to other doctors/dentist bymy request or on behalf of myself. It is understood that if you bring a friend or family member into ourfacility or ask us to call them, that you agree that we may share your personal information with them.
We require written notification if you request that we treat your information in a manner not listedabove or in our privacy policy.
_____________________________________________________________________________________________Signature Date ___________________________________________________________________________ ___________________________________________________________________________ We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: c Communications barriers prohibited obtaining the acknowledgement.
_________________________________________________________________ .
Medications and Allergies
Do you have any Allergies to: c Penicillin c Local Anesthetics c Metals (Earrings) c Acrylic c Latex c Foods Please list any other: _______________________________________________________________________________________________ Please list all current medications: ___________________________________________________________________________________ __________________________________________________________________________________________________________________ Have you been advised by your physician to take any type of pre-medication before dental treatment due to a pre-existingmedical condition? c Yes c No Is there any other information about your health which should be known? c Yes c No __________________________________________________________________________________________________________________ To the best of my knowledge, the questions on this form have been accurately answered. I understand that providingincorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform Greeneville Dental Associates, P.C. of any changes in medical status.
__________________________________________________________________________________________________________________Signature of Patient, Parent or Guardian Dental Insurance Information c Check box if NO insurance
NAME OF INSURED: ___________________________________________________________ RELATIONSHIP: __________________________
SS# OF INSURED: _______________________________________________ BIRTHDATE OF INSURED:_____________________________ EMPLOYED BY: ___________________________________________________ WORK PHONE: ______________________________________ INSURANCE COMPANY: __________________________________________ GROUP#: ___________________________________________ INSURANCE COMPANY ADDRESS: _______________________________________________________________________________________________________________________________________________________________________________________________________________Do You Have Additional Dental Insurance c No c Yes IF YES, COMPLETE THE FOLLOWING _______________________________________________________________________________________________________________________________________ NAME OF INSURED: ___________________________________________________________ RELATIONSHIP: __________________________ SS# OF INSURED: _______________________________________________ BIRTHDATE OF INSURED:_____________________________ EMPLOYED BY: ___________________________________________________ WORK PHONE: ______________________________________ INSURANCE COMPANY: __________________________________________ GROUP#: ___________________________________________ INSURANCE COMPANY ADDRESS: _______________________________________________________________________________________ MEDICAL HISTORY
Name: ____________________________________________ * May Need Pre-Med
N May not use N2O
Joint Replacement (Past 2 years or complications) Hep B/Hep C N
Tuberculosis (TB) N
Macrocytic Anemia N
Immune Diseases N
Respiratory Diseases N
Middle Ear Infection N
Pregnancy N
Inflammatory Bowel Disease (Crohn’s or Ulcerative Colitis) Claustrophobia N
Chronic Obstructive Pulmonary Disease (COPD) N
Cancer or History of Cancer/Leukemia/Non-Hodgkin Lymphomas Cancer Treatment (Radiation/Chemotherapy) Artificial Heart Valve *
Endocarditis In Past *
Congenital Heart Condition *
Seizures - Do you take Tegretol (Carbamazepine)- No E-mycin Lasix Eye Surgery (Past 2 Months) N
Trigeminal Neuralgia - Do you take Tegretol (Carbamazepine) - No E-mycin Congestive Heart Failure N
Chronic Asthma - Do you take Theophylline- No E-mycin N
Chronic Bronchitis- Do you take Theophylline- No E-mycin N
Chronic Bronchitis N
Emphysema N
Bronchiectasis N
Are you taking or have you ever taken any of the following? Phen-Fen or Redux *
Bisphosphonates (bone strengthening drugs) Didronel(Etidronate) Reclast (Zoledronic Acid) Blood Thinners / Antiplatelet Drugs Aspirin Payment in full is due to Provider when services are rendered. I accept full financial responsibility forall charges and fees incurred related to any and all services provided. I acknowledge Provider’s rightand hereby grant Provider permission to charge all fees accrued for services rendered to my ApprovedFinance Option without receipt of any additional permission or documentation from me. In the event ofdefault of payment on this account or any future accounts I may have, I agree to pay any interestaccrued and any legal or court related costs and expenses, including reasonable attorney fees, incurredby Provider related to Provider’s exercise of collection rights or other legal remedies.
Please indicate choice of payment: (circle one) REGARDING DENTAL INSURANCE (please give receptionist your card to photocopy)
We are happy to help you file your claims. We may estimate the cost of treatment and benefits, but it is
not a guarantee. Your treatment will be determined by your dental needs and your general health, not by
your dental benefit plan. We require that you pay your estimated portion plus the deductible on the day
you receive treatment. I, the undersigned, have dental insurance, and assign all the benefits of
services directly to Greeneville Dental Associates, P.C. I authorize the release of necessary information,
and use of this signature on my insurance submissions.
I, the legal parent/guardian of _____________________ , request and authorize the dental staff toperform necessary dental services for my child, including but not limited to x-rays, local anesthetics and treatment advised by the doctors. If a legal guardian is not present for the visit, I authorize the dentist to make decisions on my behalf. By way of example, but not limited to: changes in the treatment plan, the use of nitrous oxide and/or the type of restoration. (Please discuss preferences beforehand if you are planning on being absent for the visit) BROKEN/MISSED APPOINTMENTS I understand a fee will be charged for appointments cancelled with less than 24 hours notice.

Source: http://www.greenevilledental.com/forms/GDAPatientForms.pdf