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Patient Information:
Today’s Date:_____________ E-mail Address:_______________________________________________ Home Phone #________________ Cell Phone #________________Work Phone #________________ Ext #______ Name_________________________________ I prefer to called_____________________Birthdate_______________ Address__________________________________City_______________________State__________Zip____________ Employer_____________________________________Soc.Sec.#______________________ Sex____Marital Status: S___M___W___D___ Spouse’s Name_________________Spouse’s Birthdate_____________ Spouse employed by_______________________________Spouse Soc.Sec.#_________________________________ Whom may we thank for referring you?_______________________________________________________________ Responsible Party Information:
Name of Responsible Party_____________________________ to Patient________________Birthdate____________ (If different than patient)Address_______________________________________City________________State___________Zip____________ Insurance Information:
Primary Insurance:
Name of
Insured____________________________Employer____________________________Soc.Sec.#_________________ Name of Dental Insurance Co.________________________________Group #_______________________________ Address to send claims to:___________________________________________________________________
(or provide copy of dental ins. card)
Secondary Insurance:
Name of
Insured____________________________Employer____________________________Soc.Sec.#_________________ Name of Dental Insurance Co._________________________________Group #_______________________________ Address to send claims to:____________________________________________________________________(or provide copy of dental ins. card) Dental History:
Why have you come to the dentist today?____________________________________________________________ Are you in pain? ___Yes ___ No Do you require antibiotics before dental work? ___Yes ___No Your current dental health is ___Good ___Fair ___Poor Do you floss daily? ___Yes ___No Do you brush daily?___Yes ___No Do your gums ever bleed? ___Yes ___No Have you ever had periodontal disease? ___Yes ___No Are your teeth sensitive to heat, cold, or anything else?____ Do you have mobility in your teeth? ___Yes ___No Previous/Present Dentist_____________City_________ Do you have popping or clicking in your jaw?___Yes ___No Last visit date______________ Do you grind or clench your teeth? ___Yes ___No Would you like fresher breath? ___Yes ___No Would you like whiter teeth? ___Yes ___ No Are you happy with the way your smile looks? ___Yes ___No
If not, what would you change?____________________________________________________________________ MEDICAL HISTORY
Physician’s Name__________________________ City_____________________Date of Last Physical_____________ Are you sensitive or allergic to any of the following? (Please check if Yes)
Aspirin _____ Barbiturates_____Codeine _____ Latex _____ Sedatives _____ Dental Anesthetics _____ Jewelry/Metals _____ Any Antibiotics: E-Mycin____ Penicillin____ Sulfa____Tetracycline____Other____ Please List____________________ Have you had any joint replacements? Y___N___
Are you currently taking any of the following blood thinners? Y___N___ Coumadin, Warfarin, Plavix, Heparin,
Lovenox, Aggrenox, Aspirin If Yes, please circle the one you are taking Have you ever had any of the following? (Please check if Yes) ___AIDS-HIV ___Anemia ___ Angina Please list any medications you are taking or give ___Arthritis ___Artificial Heart Valves ___Artificial Joints us a list to copy: ___Chest pains ___Circulatory problems ___Diabetes ________ ___Emphysema ___Epilepsy ___Bleeding/clotting problems ___Fainting ___Hay fever/Allergies ___Heart Murmur _________________________________ ___Heart Attack ___High Blood Pressure ___Hearing problems ___Hepatitis ___Headaches ___Kidney Disease _________________________________ ___Leukemia ___Liver Disease ___Mental disorders ___Mitral Valve Prolapse ___Pacemaker ___Radiation treatment ______________________________ ___Rheumatic Fever ___Sinus problems ___Stroke ___Tuberculosis ___Thyroid problem ___Ulcer Do you suspect that you are pregnant? Y___N___ Pregnancy Due Date__Are you taking birth control pills? Y___N___ Are you under the care of a physician? ___________________For what conditions?___________________________ Is there anything else we should know about your medical history?_________________________________________ The above information is accurate and complete to the best of my knowledge. I authorize the dentist to release any information including diagnosis and the records of treatment to my insurance company and or health practitioners. I agree to be responsible for payment of all services rendered on my behalf or SIGNATURE_____________________________________________________________________________DATE________________ Written Financial Policy
Thank you for choosing TUNNEL DENTAL CARE. Our primary mission is to deliver the best and
most comprehensive dental care available. An important part of the mission is making the cost of
optimal care as easy and manageable for our patients as possible by offering several payment
Payment Options:
- Cash, Check, Visa, Mastercard or Discover Card o Allow you to pay over time with NO INTEREST¹ (over 3-18 months) o No annual fees or pre-payment penalties Please note:TUNNEL DENTAL CARE requires payment on the date of service unless other arrangements havebeen made.
For patients with dental insurance we are happy to work with your carrier to maximize your benefitand directly bill them for you.³ We require payment of any deductible and/or copay on the date ofservice. This can also be taken care of with the “credit card authorization” form. If your insurance company has not made payment within 30 days of billing, the balance will become the responsibility of the patient.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistryyou want or need.
I understand this policy and agree to pay for all services rendered on my behalf or my dependents.
Date_______________ Signature ___________________________________________________ Cancellation Policy
We would greatly appreciate a 48 hour notice from any patient (or patient representative) shouldthey need to reschedule or cancel an appointment. We reserve the right to apply a cancellation feeof $75 if this policy is not respected.


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