Patient Appointment Form - Pawleys Island Dentistry

2Acknowledgment

3Medical History

4Dental Info

5Review

Patient Information

Patient Information Form

Patient Name *

Date *

Status *

Married
Single
Child

Phone *

Email Address *

Address *

Address Line 1

City

State

Zip Code

In case of emergency, these contact information will be used

Name *

Phone Number

Would you like to be reminded of your appointment by

Text
Email
Phone Call

Responsible Party Information

Name *

Gender *

Male
Female

Security

M/S/C

Phone *

Address *

Employment Information

the following is for: the person is responsible for the payment and insured

Employee (Name & Occupation) *

First

Last

Address *

Phone *

Insurance Information

Name of Insured *

Is Insured a Patient? Yes/No *

Insured's Date of Birth *

ID# and GR# *

First

Last

Patient relationship to insured *

Self
Spouse
Child
Other

Primary Insurance Plan Name *

Phone *

Address *

Address Line 1

City

State

Zip Code

Secondary Insurance (if applicable)

Secondary Insurance

First

Last

Insured's Date of Birth

ID# and GR#

First

Last

Patient relationship to insured

Self
Spouse
Child
Other

Secondary Insurance Plan Name

Phone

Address

Address Line 1

City

State

Zip Code

Acknowledgement of Receipt of Notice of Privacy Practices

i,__________ had received a copy of notice of privacy

_________________________(Please Print Name)

_________________________(Signature)

_________________________(Date)

Whom we share information with *

First

Last

if this form is signed by a personal representative on the behalf of a patient, complete the following

Personal representative name *

Relationship with patient *

Medical History

Patient Name *

Date *

if you have the following disease just mark (✔) the checkbox below *

Hospitalization for
Asthma
Hepatitis
Liver Disease/Jaudice
AIDS/HIV
Heart Concerns
HPV
Heart Attack within 1-5 Y
Heart Attack above 1-5 Y
Latex Sensitivity
Heart Valve Repair/Replaced
Artificial Joints Repair
Kidney Trouble
Diabetes Types i/ii
Cancer
Stroke
Radiation/Chemotherapy
Congenital Heart Disease
Epilepsy/Seizures
High BP / Low BP
Sickle Cell Disease
Mitral Valve Prolapse
Tuberculosis
High Cholesterol
Thyroid disease
Lupus
Rheumatoid Arthritis
Neurological Disorder
Psychlatric/Psychological
Have you taken Bisphosphonates for osteoporosis
Are you smoker/ previously smoked/ or tobacco used?

if you have the following Alergies just mark (✔) the checkbox below *

Aspirin
Penciline
Erythromycin
Tetracycline
Sulfa
local anesthetic
Fluoride
Metals(nickel, gold. silver )
Latex
Other

List all the medication/supplements, and or Vitamins ever had within last two years

Drug Name and its Purpose *

Patient Name *

Date *

Dental Information

Please ✔ the option below if you have:

Checkbox Items *

Any teeth sensitive to hot, cold?
Are you teeth becoming more crooked, crowded, or overlapped?
Do you clench your teeth daytime or make them sore?
Have you ever whitened (bleached) your teeth?
Have you been disappointed with the appearance of previous dental work?
Do you have a problem with your jaw joint?
Are you teeth developing spaces or becoming more lose?
Do you have any problem with sleep (i.e. restlessness) wakeup with a headache?
Have you felt uncomfortable or unconscious about the appearance of your teeth?
Did you have braces, orthodontic treatment or had you bite adjusted?

What do you think about present state of your mouth? *

Perfect
Good
Ok

How healthy do you want your mouth? *

Perfect
Good
Ok

Tell us about your dental experience? *

What caused you to leave your last dentist? *

What would you like to change your smile? *

What would it take for you to trust us to be your dentist? *

Do you have any family or friends that already come to our office? *

Has fear ever been an issue for you in a dental office? *

Has time ever been a factor in getting your dental work done? *

Has a cost of dental treatment been a concern for you? *

We have the unique ability to look at your mouth from 2 different perspective. what combination would you like us to use for you? *

As a general dentist
As a cosmetic dentist

At what time do want us to initiate treatment? *

When my tooth hearts or break
When something is not ideal
When something is not Worsening

We would like to appreciate your online feedback. To make it easy, we've put together this handout that details the steps needed to leave a review on the most popular reviews site.

if you have a concern with your experience at Pawleys Island Dentistry, please call our office at office 843-237-8433 pr by email at: office@smilepi.com.

Thank You!

FACEBOOK: Login into your Facebook account and enter our office name Pawleys Island Dentistry. When on our page you can hit the star for the rating and then write the review. Once done, hit saved and you are finished.

843-237-8433

office@smilepi.com

Patient Information

Responsible Party Information

Employment Information

Insurance Information

Secondary Insurance (if applicable)

Acknowledgement of Receipt of Notice of Privacy Practices

Medical History

Dental Information

Pawleys Island
Dentistry

Contact
Information

Social Media

843-237-8433

office@smilepi.com

Patient Information

Responsible Party Information

Employment Information

Insurance Information

Secondary Insurance (if applicable)

Acknowledgement of Receipt of Notice of Privacy Practices

Medical History

Dental Information

Pawleys IslandDentistry

Contact Information

Social Media

Pawleys Island
Dentistry

Contact
Information