7651 S.W.

Hwy

200 .

STICKNEY DEI{TAL,LLC
SUITE 10i, CIRCLE SQUARE CENTER TELEPHONE (3s2) 854-2000

OCALA, FLORIDA 34476

Thank you for selecting our dental healthcare ieam
!

?/)elP"ttP
O Married Single Divored tr Nanre: D Mr fl Ms O Mrs D Dr
Address:

will strive to provide you with the best possible dental care. Tb help us meet all your dental healthcare needs, please fill out this form completely in ink. Ifyou have any questions or need assistance, please ask us- we will be happy to lrelp.
We

Patient nInformation D
Widow

(coNFrDENrrAr)

Today's Date

Age:
City
Rusiness Phone

Birthday Zip:

Home Phone By what name may we call you?

Place olErnployment Person Responsible for this Account

Cell Phone

Social Security Number olPatient: Social Security Number of Person Responsible Do you have Dental Insurance?

Driver's License No
Group # Address
Telephone #

Ilyes. Name of Company:

If

yes. also give Social Security Number

ol Spouse
Phone #

D.O.B.

Physician
Closest Relative or Friend NOT living with you:

City:

Whom may we thank lor referring you to our ofifice?

Is there a specific dental problem'l

How

will you pay fbr this account?

Personal Check

Credit Card

Cash

YES

NO

HEALTH HISTORY
(Please Answer Each Question)

2.

HAS A PHYSICIAN EVER INFORMED

YOU THAT YOU HAD A HEART AILMENT, HEART MURMUR, MITRAL VALVE PROLAPSE, ETC.?

IF SO. PLEASE DESCRIBE: NAME OF PREMEDICATION:

YES

NO

3. 4. 5. 6. 1. 8.
I

YES

NO

STINT?

LATEXALLERGY?
BLOOD THINNERS?.. TUMORS, GROWTHS, OR CANCER? ANY BLOOD DISEASE?.....
..

ANY LIVER

9. ANY KIDNEYDISEASE?

DISEASE?.....

2I

1I. ALLERGY TO OTHER ANTIBIOTICS'/ 12. VENEREAL DISEASE? 13. ANEMIA'1...................... I 4. PARKTNSONS DISEASE? ....................... I5. H]GH BLOOD PRESSURE, STROKE.? .. 29.
DO YOU WEAR REMOVABLE PARTIAL DENTURES?

O. ALLERGY TO PENICILLIN'?..................

22.

HEPAIITIS? A ARTHRITIS?

C .....,........,....,

26. IMPI,ANT? 27. BLEEDINGPROBLEMS?, 28. ALZHETMERS I .............. 29. BISPHOSPHONATE,S (Boniva.

Zometia. Fosamu)?

30.

ISITSATISFACTORY? BOTTOM: HOW OLD? IS IT SATISFACTORY? EXPLAIN: ARE YOU ALLERGIC TO ANY KNOWN MATERIALS RESULTING IN HIVES. ASTHMA OR ECZE}'/.A?
IF YES, PLEASE DESCRIBE:

TOP:

HOWOLD?

33. 35.

HAVE YOU EXPERIENCED ANY COMPLICATIONS OF HEALING?

AREYOUPREGNANT?

]6.

DUE DATE ARE YOU NOW TAKING DRUCS OR MEDICATION? IF SO. PLEASE NAME

YES
38. 39.

NO

HAVE YOU HAD RADIAIION TREATMENTS? DO YOU HAVE SINUS PROBLEMS?.........

..

WHEN?

40. 41.
42.

DoYoUHAVEANYGRowTHSoRSoRESPoTSINYoURMoUTH?......

43. 44. 45. DO YOU HABITUALLY CLENCH YOUR TEETH DURING THE DAY OR NIGHT?,....
HAVF,

YOI] EVER HAD ANY REACTION OR ALLERGIC SYMPTOMS TO ANESTHETICS? IF SO, PLEASE NAME:

PROLONGED BLEEDING FOLLOWING EXTRACTIONS IN THE PAST?.

..TRENCH MOUTH''?...... 46
47 48

DOYOI,] NOWHAVE BLEEDING GUMS? HAVE YOU EVER BEEN INSTRUCTED IN CARING FOR YOUR GUMS?............, HAVE YOU EVER BEEN INSTRUCTED IN THE PREVENTION OF TOOTH DECAY? WHEN WAS YOUR LAST FULL MOUTH X-RAY TAKEN? HOW LONG HAS IT BEEN SINCE YOUR LAST DENTAL VISIT?..............
PI]RPOSE?...... WHERE?

49
50

51.
52.

HAVE YOU HAD ANY RADIATION TR,EAIMENT TO THE HEAD OR NECK AREA? ..........,....,"... DO YOU HAVE ANY JOINT REPLACEMENTS, SUCH AS KNEE, HIP, ETC.? .........,.....
IF YES TO #50. HAS PHYSICIAN ADViSED YOU TO PREMEDICATE FOR DENTAL APPOINTMENTS?....

53.

Consent for Services

Asaconditionolyourtreatmentbythisolice, financialarrangernents mustbemadeinadvance. Thepracticedependsuponreimbursementfromthepatientsfor
the costs incurred in their care and financial responsibility on the part ofeach patient must be determined before treatment

All emergency dental seruices, or any dental

lormed.

services perlormed

*'ithout previous financial arrangements, must be paid for in cash at the time services are per-

patients u,ho cany dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance lorms or assist in making collections from insurance companies and will credit any such collections to the patient's account. Hou,ever, this dental office cannot render services on the assumption thatpur charges will be paid by an insurance
company.

A seruice charge of l,/zyo per month

arrangements are satisfied.

(I

8% per annum) on the unpaid balance

will

be charged on all accounts exceeding 60 days, unless previously written financial

I understand that the fee estimate listed for this dental care can only be extended for

a period

ofsix months from the date ofthe patients examination.

ln consideration for the professional seruices rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value ofsaid services to said Doctor, or hi s assignee, ar the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objectecl to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attomey fees if suit be
instituted hereunder. I agree in the event ofnon-payment, to bear the cost olcollection, and/or court costs and reasonable legal fees should this be required.

I grant my permission to you or your assignee, to telephone me

at home or at my

work to discuss matters related to this form.

I have read the above conditions oftreatment and

agree to

their content.
Relationship to Patient:

Date:
Signature ofpatient, or guardian

MEDICAL HISTORY UPDATES