Blackcanyondental.com

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_______________________________ Insurance Responsibility
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. Dental Insurance
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 ____________________________ X_________________________________________
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
Consultation
Family Physician Name ___________________________________________________Phone # ______________________________
Are you allergic to any medications, foods or products such as latex? _________________________________________________
____Codeine
____Penicillin
____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:
__Artificial joint
Please list any other condition
not previously mentioned:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
WOMEN ONLY
__Dip ____cans/day for ___yrs


List all serious illnesses, hospitalizations, and surgeries in the last 5 years:________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Dental History
___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

Source: http://www.blackcanyondental.com/sites/default/files/Patient_Information_Form.pdf