Patient Medical History Form

Adult Medical/Dental History
Patient Information
Patient Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Ext
Email
example@example.com
Preferred method of contact?
Employer or School
How did you find out about us?
Emergency Contact
Emergency Contact Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Medical Information
Have you had a recent exposure to any communicable infectious diseases? (Measles, Chicken Pox or Tuberculosis)
In the last 24 hours have you had a new cough, shortness of breath, fever, chills, diarrhea or other flu-like symptoms?
Have you previously been or are currently under the care of a health care professional for any kind of specific condition or syndrome?
Have you had a recent exposure to any communicable infectious diseases? (Measles, Chicken Pox or Tuberculosis)
Do you require premedication prior to hygiene (cleaning) appointments or dental treatment?
Have you had a recent exposure to any communicable infectious diseases? (Measles, Chicken Pox or Tuberculosis)
Have you ever had any major surgeries?
Are you taking any medications (including birth control, vitamins, etc.)
Do you have any known allergies?
For Females : Are you pregnant or nursing, or a possibility you could be pregnant?
Please check any of the following below that you have ever had a bad reaction to
Please select:
Please select:
Have you had or do you have any of the following?
Please select
Please select
Dental Information
Name of previous dental office
Last dental check-up/cleaning?
How often do you visit the dentist?
Are you having any problems that require immediate attention?
Do any of the following cause tooth discomfort?
Do you clench or grind your teeth?
Have you ever had orthodontic treatment (Braces or Invisalign?)
Are you interested in straightening your teeth?
Have you ever considered straightening, bleach, crowns or veneers?
Do you have spaces you would like closed?
How do you feel about the appearance of your teeth?
Is there anything else you wish to share/discuss about your teeth or smile?
ASSIGNMENT OF BENEFITS

I authorize my dental benefits plan administrator to release information contained in claims and pre-authorizations submitted by SunRiver Dental both electronically and manually. I also authorize communication of information related to the coverage details and services rendered to the named dental office. This authorization shall continue in effect until the undersigned revokes the same.

I hereby assign my benefits, payable from claims submitted electronically and manually, to the treating dentist at SunRiver Dental and authorize payment directly to him/her as my plan allows. This authorization shall continue in effect until the undersigned revokes the same.

I understand that SunRiver Dental is a third party company and that my insurance policy is an agreement between me, my employer and the insurance company. I understand that though SunRiver Dental has my plan on file and submits claims on my behalf, that I am ultimately responsible to know my plans details and guidelines and that I am financially responsible for any treatment and deductibles not covered under those guidelines.
Primary Insurance
Your insurance company/carrier
Insurance Address
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Policy holder's name
Policy holder's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Group or policy number
I.D./Certificate number
Secondary Insurance (If Applicable)
Your insurance company/carrier
Insurance Address
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Policy holder's name
Policy holder's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Group or policy number
I.D./Certificate number
I authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

I authorize my insurance company to make payment directly to this dental provider.

As you may know your insurance covers only a percentage of the total fee of services provided and we therefore require a credit card number to accept assignment from your insurance carrier. This is with the understanding that our office will be calling you for authorization to use this credit card to pay the difference not paid by your insurance provider.

I understand that anything not covered by my dental insurance is my full responsibility to pay. Our office will help to provide the most accurate estimate possible, but it is ultimately the patients responsibility to know what their insurance coverage details are.
OFFICE POLICIES

I understand that...
- All patient balances are due immediately after treatment is rendered. Only exception is if a payment plan agreement was put in place prior to the treatment date, in which case 40% down is due at time of treatment.
- If there is dental insurance on the account, I understand that the clinic has established the patient balance based on the information I have provided. And that final treatment payment is subject to the terms and conditions of my insurance provider on the date of service. As such, until payment and/or a response is received from my insurance provider, no patient portion is final.
- Estimates and treatment plans are based upon information gained from the examination. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. Estimates are preliminary only and lab charges (if applicable) have been estimated and included in the total.
- Estimates do not take into consideration any money that was billed toward my financial maximum or treatment limits that may have been used at other dental clinics or specialist’s offices, as SunRiver Dental does not have access to those claim details and amounts.
- A submission to my insurance provider will be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment.
- For the comfort of their patients and team members, that SunRiver Dental is a scent free office
- Any verbal or physical abuse towards the Dentists, team members or patients, will not be tolerated and my result in immediate dismissal from the clinic.
CANCELLATION POLICY

I understand that...
- I have time reserved for my appointment(s) and that SunRiver Dental requires that any changes to appointments are made with a minimum of 2 business days notice. If I do not arrive to the appointment and/or fail to notify the clinic with the required notice, a $125 booking deposit may be required to reschedule. And if I fail to arrive for the rebooked appointment, the deposit will be taken as a fee and not returned.
I declare that I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history, and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that I assume responsibility for any and all fees associated with the procedures and services.
Name and Email of Signing person
First & Last Name
Email
example@example.com
Signature
Should be Empty:

Adult Medical/Dental History

Patient Information

Emergency Contact

Medical Information

Have you had or do you have any of the following?

Dental Information

Primary Insurance

Secondary Insurance (If Applicable)

Name and Email of Signing person