Name _______________________________________________________ DOB _____________ Soc. Sec. # ________-______-_________ Last Name
Address ____________________________________________________ City ________________________ State ______ Zip __________
How did you hear about us? ________________________________________________________________________________________
Sex: F M Marital Status _____________________ Drivers License # _____________________________
Home Phone ___________________________ Cell Phone ___________________________ Work Phone __________________________
Patient is a student Yes No If yes, school _______________________________________________________ Full time Part time
Employer ____________________________________________________ Email Address ________________________________________
Emergency Contact Name ________________________ Home/Cell Phone ____________________ Work Phone _____________________
Responsible Party Information (if other than patient above)
Person responsible for paying fees ___________________________________________________________________________________
Social Security #_______________ DOB _________ Relationship to pt ____________ Resp. Party Drivers License #___________________ Address __________________________________________________ City______________________ State ________ Zip ____________ Home Phone _________________________ Cell Phone ________________________ Work Phone_______________________________
We will file your insurance one time as a courtesy to you. If your insurance company does not pay within 60 days, you will be responsible for the remaining balance. It is YOUR responsibility to provide us with accurate insurance
information, if you do not – we cannot appropriately file your claim.
Authorization for Treatment
Subscriber Name ______________________________________
Relation to patient ___________________DOB _____________
I hereby authorize Black Canyon Dental to administer
Subscriber Soc. Sec.# __________-__________-___________
such medications and perform diagnostic, photographic, and therapeutic procedures as may be
Subscriber Address ____________________________________
necessary for proper dental care. The information on
City _____________________State ________Zip____________
this page and dental/medical history is correct to the
Subscriber Employer __________________________________
best of my knowledge. I also grant the right to Black
Work Phone _________________________________________
Canyon Dental to release my dental history and records to my insurance company for payment.
Insurance Company ___________________________________
Ins. Company Phone Number ____________________________
Insurance Company Address ____________________________
Patient/responsible party Date
Subscriber # _____________________ Group # _____________
1544 Oxbow Dr., Suite 230 Montrose, Colorado 81401
Name _______________________________________________________________________ DOB __________________________
All information given is strictly confidential and will not be released to anyone without approval. It is for your safety
that our doctors know your entire medical/dental history to provide safe and complete treatment.
Primary reason for this dental visit: Routine Exam Emergency
Family Physician Name ___________________________________________________Phone # ______________________________ Are you allergic to any medications, foods or products such as latex? _________________________________________________
____Aspirin ____Acrylic ____Latex ____Sulfa
Have you ever taken any Bis-phosphonate medications (ie: Zometa, Aredia, Boniva, Actonel, Fosamax, Skelid, Didronel?) YES NO
List all medications you are currently taking. Please include all prescription, inhaler, homeopathic, and herbal medications:
Check any of the following that you have had or presently have:
Please list any other condition
not previously mentioned:
__Dip ____cans/day for ___yrs
List all serious illnesses, hospitalizations, and surgeries in the last 5 years:________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________
___Do your gums bleed while brushing or flossing?
___Unhappy with the appearance of your teeth?
___Are your teeth sensitive to hot or cold?
___Unfavorable dental experience/ dental fears?
___Are your teeth sensitive to sour or sweet?
___Problems with anesthetic/hard to numb?
___Do you have sores or lumps in your ears or mouth?
___Previous orthodontic treatment? When?_________________
___Have you had any head, neck or jaw injuries?
___Previous periodontal treatment? When?_________________
___Do you experience any clicking or popping in jaw?
How many times do you brush per day?____________________
___Do you experience any problems with opening or closing?
How often do you floss? ________________________________
___Do you have frequent headaches? Morning/Evening?
Do you use a manual or electric toothbrush? ________________
Do you use any type of mouth rinse? ______________________
___Do you have an unpleasant odor or taste in your mouth?
Is there anything you would change about your smile?
___Have you had difficulty with extractions in the past?
___Have you ever had instruction on the correct way to brush?
Are you interested in having cosmetic work done?
___Have you ever had instruction on correct gum care?
The responses on this questionnaire are accurate to the best of my knowledge. If there is any change in my medical status
Patient Signature or Parent/Guardian of child _____________________________ Date: ______________
1544 Oxbow Dr., Suite 230 Montrose, Colorado 81401
LEGAL BULLETIN Phone (570) 523 – 1104 Update August, 2000 This bulletin will provide some general, introductory information about AIDS and related law as it concerns prisoners. This is a overview. It is important that you follow up with your own research. Introduction AIDS stand for Acquired Immune Deficiency Syndrome. It is acquired, meaning that it can be transferred to an indi
Tomato pill to beat heart disease Monday June 1st 2009, By Dana Gloger The tomato is the latest 'superfood' hailed as a boost to health A WONDER pill that uses the fat-busting power of tomatoes could save hundreds of thousands of lives, heart experts revealed yesterday. British scientists have found a way to put all the antioxidant goodness in the skin of ripe tomatoes in a pill. It is sa