Renew Dental - Patient Forms "*" indicates required fields Step 1 of 5 20% PATIENT INFORMATIONMarital Status* Married Single Minor Student Gender* Male Female Last Name* First Name* Middle Initial Preferred Name Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birthdate* MM slash DD slash YYYY Age* Social Security #* Home Phone Cell Phone* Email* Place of Employment Work Phone Emergency Contact Relationship Phone REFERRAL INFORMATIONWhom may we thank for referring you to our practice?Select Option HereAnother PatientAnother Dental/Doctor OfficeYellow PagesFacebookGoogleSchoolWorkOtherName of person or office referring you to our practice: FINANCIAL RESPONSIBLE PARTY(if under 21, MUST be parent or legal guardian)Check if below information is the same as the above. Same as above Name (First, Middle Initial, Last)* Relationship to Patient* Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birthday* MM slash DD slash YYYY Age* Social Security #* Home Phone Cell Phone* Email* Place of Employment Employer Phone AUTHORIZATION(ALL Patients or Legal Guardians MUST Sign)I authorize Marquis Dental Center/Renew Dental to perform diagnostic procedures and treatment as they may be necessary for proper dental care. I authorize release of any information concerning mine or my child’s health care, advice and treatment provided for the purpose of evaluating and administering claim for insurance benefits or credit information. I authorize payment of insurance benefits directly to Marquis Dental Center/Renew Dental, otherwise payable to me. I understand that all insurance co- pay estimates are due the day of service. I understand that I am responsible for all charges on this account. If no insurance, I understand that all charges are to be paid at the time services are rendered unless prior arrangements have been made. I authorize all insurance payments to be paid directly to Marquis Dental Center/Renew Dental. I understand that if the insurance payment is sent to me, it is my responsibility to forward payment on to Marquis Dental Center. All balances are due within 30 days. If payment in full or payment arrangements are not made, I understand that my account could go to an outside collection agency on any account over 90 days old. Finance charges will incur on any account over 60 days old in the amount of 12% annually (1% monthly). If turned over for collections, I understand that my account will be assessed collection and attorney fees in the amount of up to 45%. I understand that my account will be charged a $40 fee for any returned check due to NSF funds or closed accounts.Patient or Legal Guardian Signature* Date* MM slash DD slash YYYY MEDICAL HISTORYName of Primary Care Physician? Have you ever been hospitalized or had a major operation?*ChooseYesNoIf yes above, please explainAre you ALLERGIC to any medications or substances?*ChooseYesNoIf yes above, please check any you are allergic to below Aspirin Penicillin Codeine Acrylic Metal Latex Rubber Other If "Other" above, please list medications or substancesWOMEN: Pregnant/Trying to Get Pregnant Nursing Taking Oral Contraceptives If you "check" below any of the starred questions, please call prior to your appointment. PREMEDICATION may be required**(check all that apply) AIDS/HIV Positive Allergies (Pollen/Dust) Alzheimer's Disease Anemia Angina/Chest Pains Arthritis/Gout Artificial Heart Valve* Artificial Joints* Asthma Breathing Problems Cancer Chemotherapy Cold Sores Convulsions Diabetes Drug Addiction Emphysema Epilepsy/Seizures Excessive Bleeding Fainting/Dizziness Glaucoma Hay Fever Heart Attack/Failure Heart Disease Heart Murmur* Heart Surgery* Hepatitis A B C Herpes High Blood Pressure Hypoglycemia Kidney Problems Liver Disease Lung Disease Mitral Valve Prolapse* Nervousness Organ Transplant* Pacemaker Pain in Jaw Joint Psychiatric Care Radiation Renal Dialysis Rheumatic Fever* Rheumatism Scarlet Fever Sinus Trouble Sleep Apnea Steroid Therapy Stomach Disease Stroke Thyroid Tuberculosis (TB) Tumors/Growths Ulcers Other Have you ever had any illnesses not checked above?*ChooseYesNoIf yes, please explainList of MedicationsDo you smoke?*ChooseYesNoIf yes, how many packs per day? Do you use any other form of tobacco?*ChooseYesNoIf yes, what kind? Number of sodas or sweet drinks per day?* To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform Marquis Dental Center/Renew Dental.PATIENT OR LEGAL GUARDIAN (IF PATIENT IS UNDER 21) SIGNATURE* First Last Date* MM slash DD slash YYYY DENTAL HISTORYName of previous dentist Date of last dental visit How long since last cleaning? Reason for changing dentistDescribe your current dental problem*APPREHENSIONDo you experience fear of having dental treatment performed?* Yes No Have you had an unpleasant dental experience?* Yes No Do you dread the numbing after effects?* Yes No Do you feel you need any help overcoming fear?* Yes No TEETH PROBLEMSAre your teeth sensitive to hot, cold, sweets or pressure?* Yes No Does food wedge between certain teeth?* Yes No Do you have areas that are hard to floss?* Yes No GUM PROBLEMSDo your gums ever bleed when you brush or floss?* Yes No Have your gums receded from your teeth?* Yes No Do you have bad breath or a bad taste in your mouth?* Yes No HEADACHES/FACIAL PAINDo you have frequent headaches?* Yes No Do you experience popping or clicking upon opening or closing?* Yes No Do you experience facial muscle pain while chewing or when you wake up?* Yes No YOUR SMILEDo you think you have a pretty smile?* Yes No Are your teeth crooked?* Yes No If so, does this bother you? Yes No Have you had any cosmetic dentistry?* Yes No Would you like to have whiter teeth?* Yes No Do you have any fillings or blemishes on your teeth that make them look bad?* Yes No PLEASE LIST ANY CONCERNS THAT YOU WOULD LIKE TO DISCUSSPatient Signature (Legal Guardian if under 21)* First Last Date* MM slash DD slash YYYY Patient's Name First Last Date of Birth MM slash DD slash YYYY AUTHORIZATION TO RELEASE MEDICAL INFORMATIONI do hereby give my permission for Marquis Dental Center/Renew Dental to discuss any and all medical/dental records and/or bring my child (if under 21) for dental care/treatment with the following physician/person in regards to myself or my child (if under 21):*** PLEASE NOTE THAT IF A PERSON IS NOT LISTED ON THIS FORM THAT WE WILL NOT BE ABLE TO DISCUSS ANYTHING ABOUT YOU OR YOUR CHILD. ALSO, IF A CHILD IS A MINOR, ANY PERSON THAT WILL BE BRINGING YOUR CHILD TO THE DENTIST MUST ALSO BE LISTED. IF SOMEONE BRINGS YOUR CHILD AND THEY ARE NOT LISTED, WE WILL NOT BE ABLE TO SEE THEM AND THEY WILL HAVE TO BE RESCHEDULED. IT IS YOUR RESPONSIBILITY TO KEEP THIS LIST UPDATED AS NEEDED. *** INITIALS* ACKNOWLEGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESI have received a copy of Marquis Dental Center/Renew Dental Notice of Privacy Practices.Signature of Patient or Legal Guardian (if under 21)* First Last Date* MM slash DD slash YYYY Section 1 - Patient Sleepiness Scale: Have you ever been told you stop breathing while asleep?* Yes No Have you ever fallen asleep or nodded off while driving?* Yes No Have you ever woken up suddenly with shortness of breath, gasping or with your heart racing?* Yes No Do you feel excessively sleepy during the day?* Yes No Do you snore or have you ever been told that you snore?* Yes No Have you had weight gain and found it difficult to lose?* Yes No Have you taken medication for, or been diagnosed with high blood pressure?* Yes No Do you kick or jerk your legs while sleeping?* Yes No Do you feel burning, tingling or crawling sensations in your legs when you wake up?* Yes No Do you wake up with headaches during the night or in the morning?* Yes No Do you have trouble falling asleep?* Yes No Do you have trouble staying asleep once you fall asleep?* Yes No Section 2 - Signs & Symptoms {Check all that apply):* Hypertension Snoring Diabetes Depression Grind Teeth Acid Reflux Stroke/Heart Disease Unrefreshed Sleep Family history of Snoring or Sleep Apnea None of the above Section 3 - Sleep History {Check all that apply):* I have been diagnosed with a sleep disorder I currently use a CPAP machine. I use my CPAP less than 5 times a week. I would prefer an oral appliance. None of the above EmailThis field is for validation purposes and should be left unchanged.
