Lifetime Smiles Health History Form

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Lifetime Smiles Health History Form

Step 1 of 5 - Personal Information

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Welcome to Lifetime Smiles! To assist us in serving you, please complete the following confidential form.
Patient's Name*
First Last
Preferred Name
Social Security#
Date Of Birth*
MM
DD
YYYY
Gender*
- Male
- Female
- Decline
Family Status*
Parent's Name (If Minor i.e. Age < 18)
Contact Information
Email*
Cell Phone*
Home/Work Phone
Residential Address*
Street Address Address Line 2 City State ZIP Code
Occupation
Referral
How did you hear about us?*
Other*
Friend's | Family Name*
Please provide their name, so we can thank them.
Doctor's Name*
Please provide their name, so we can thank them.
Why are you choosing us?*
- Change of residence
- Change of insurance
- Your office Is closer
- My previous dentist retired, closed or passed away
- I had bad experience with my previous dentist
- I am unhappy with my treatment
- My previous dentist is too expensive
- You were recommended
- I don't have a previous dentist
- Other
Other (Why are your choosing us)*
What is the reason for your dental visit today?*
- Complete Exam
- Dental Emergency
- Cleaning
- Cosmetic
- Second Opinion
- Implant Consultation
- Invisalign Consultation
- Other
Other (reason for your dental visit)*

Dental Insurance
Do you have dental insurance?*
- Yes
- No
On your dental insurance, are you the policy holder (primary subscriber)?*
- Yes
- No
Policy Holder (Primary Subscriber) Name*
Policy Holder (Primary Subscriber)'s Date Of Birth
MM
DD
YYYY
Name of Insurance Company*
Subscriber Id / Member Id*
Typically this is on your insurance card, otherwise, it can also be your SSN.
Group Name or Number (if available)

Please check if you have or have had any of the following*
- Abnormal bleeding
- Alcohol/Drug abuse
- AIDS/HIV +
- Anemia or Blood disorders
- Arthritis or Rheumatism
- Artificial joint or Valve
- Asthma, COPD
- Back problems or Back surgery
- Chemotherapy or Radiation
- Cold Sores or Herpes
- Diabetes
- Digestive disorder
- Epilepsy, Seizures, or Fainting
- Frequent sinus infections
- Glaucoma
- Head Injury
- Heart disease, Angina, Heart attack
- Heart murmur or defect
- Hepatitis or other Liver disease
- High Blood pressure
- High Cholesterol
- Kidney disease or Dialysis
- Migraines or Frequent headaches
- Nervous or Mental Disorders
- Osteoporosis
- Pacemaker
- Respiratory problems
- Scarlet or Rheumatic Fever
- Stroke
- Ulcers
- Thyroid problems
- Tuberculosis
- Venereal Disease or HPV
- NONE
- Other
Select NONE if not applicable
Artificial joint or Valve Date*
MM
DD
YYYY
Chemotherapy or Radiation Date*
MM
DD
YYYY
Pacemaker Date placed*
MM
DD
YYYY
Other specify*
Are you taking any of the following?
Are you taking any of the following?*
- Aspirin
- Blood Thinners
- Antibiotics
- High blood pressure medicine
- Antidepressants, tranquilizers
- Insulin, Glucophage,or other Diabetes drug
- Nitroglycerin
- Cortisone or other Steroids
- Osteoporosis medicine
- Have you ever taken Bisphosphonates, a class of drugs used to treat osteoporosis or bone cancer?
- NONE
- Other
Select NONE if not applicable
Other specify*
Allergies or Adverse Reactions
Allergies or Adverse Reactions*
- Latex materials
- Penicillin
- Nickel or metal jewelry
- Local anesthetics ("Novocain")
- Codeine, hydrocodone, or other narcotics
- Sulfa drugs
- Barbiturates or sedatives
- Aspirin
- NSAID’s
- NONE
- Other
Select NONE if not applicable
Other specify here*
Please list all medications you are currently taking
Do you smoke or use chewing tobacco?*
- Yes
- No
Only Women
Pregnant or may be pregnant
- Yes
- No
Expected delivery date
Date Format: MM slash DD slash YYYY
Currently Breastfeeding
- Yes
- No
Taking hormones or contraceptives
- Yes
- No

Physician Name:*
Physician Phone Number*
Do you have any disease, condition, or problem not listed above, or that needs further clarification?
Please list the name and phone number of your emergency contact
Have you ever had any complication following dental treatment?*
- Yes
- No
If yes, please explain

Office Policies
Privacy Policy*
Thank you for choosing our office for your dental needs! We are so glad you are here! We appreciate your trust and look forward to working with you. In order to better serve you, we ask that all patients read and sign our OFFICE POLICIES. If you have any questions, please ask the front desk.

1. INSURANCE: We are pleased that you have dental insurance! Your dental insurance benefits are a contract between yourself, your employer, and your insurance carrier. We are not part of that contract. As a courtesy to you, we will try to verify your insurance eligibility benefits prior to your appointment. Please notify us immediately if your insurance coverage changes. Not all dental services are covered under your dental policy. Each policy varies in exceptions, exclusions, waiting periods, and limitations. Your insurance is your responsibility; you are ultimately responsible for knowing all guidelines, exclusions, waiting periods, and limitations. Should you have any questions or need explanations about your insurance benefits, please ask. Insurance estimates are provided as a courtesy, and are never a guarantee of your benefits. In the event that your insurance carrier pays less than the estimated amount, you are responsible for the remaining unpaid balance. You are responsible for the balance in the event that insurance benefits are denied.

2. FILING INSURANCE: As a courtesy to you, we will electronically file insurance claims and accept assignment of benefits on your behalf. Often, the insurance company will request additional information such as a college student’s full-time status, proof of enrollment, etc. Failure to provide additional information to our office may result in a denial of insurance benefits.

3. PAYMENT: Payment is due at the time of services rendered (this includes yearly deductibles, copayments, and/or estimated out of pocket portions). Additionally, if you have an outstanding balance following an insurance payment, you will be expected to pay the balance prior to additional treatment. Our office offers Third Party Financing if needed to assist you in paying for necessary treatment.

4. OVER DUE BALANCES: If your account balance exceeds 30 days, you will receive a notice informing you that your account is overdue. If you do not pay your balance or arrange a payment plan within 10 days of notification, your account will be turned over to a collections agency. In this event, there is a collection fee that will be added to the balance. The collection agency will report any unpaid balance to the major credit bureus.

5. RETURNED CHECKS: There will be a $35 fee for all returned checks. In the event of a returned check, your balance and fee must be paid via credit card or money order within 10 days of notification. If it is not paid, we will treat it as an over due balance.

6. CHANGES IN PERSONAL INFORMATION: Please notify our office of any changes in your address, telephone numbers, or email address.

7. CANCELLATIONS/FAILED APPOINTMENTS: We reserve the right to charge a fee of $35-$100 for any appointment missed or cancelled without a 24 hour notice. If a conflict with your appointment time arises, please call us immediately.

8. INTERNET COMMUNICATIONS: We are a paperless office! By signing the office policies form below, I also grant my permission to the dental office to upload and store confidential information to the secured website of the dental practice. I also grant my permission to the dental practice to file my insurance claims electronically.

I have read and understand the office policies of the practice and agree to the terms.
Signature*
Date
Email
This field is for validation purposes and should be left unchanged.