Choose your preferred location:
Westlake Office
Circle C Office
Date:
1. Patient's Name:

Driver's License#:

Last
First
Middle
2. Address:
Street
City
State
Zip Code
3. Home Phone:
Birth Date:
Social Security #:
4. Email Address:
Cell Phone:
Work Phone:

5. Person Responsible for Payment:
6. Address:
Street
City
State
Zip Code
Last
First
Middle
7. Relationship to Patient:

If minor, list parent’s names:

Father:

First
Last
Mother:
First
Last
8. Social Security #:
9. Birth Date:
10. Driver’s License#:
11. Home Phone:
12. Employer:
13. Work Phone:
14. Patient's Spouse Name:
Last
First
Middle
15. Spouse’s Employer:
16. Occupation:
17. Work Phone:
DENTAL INSURANCE INFORMATION (need copy of card)
18. Insured Name:
19. Insured Birth Date:
20. Insured’s Address (if different from above) :
21. Insured’s Social Security #:
22. Insured’s Employer:
23. Insurance Company Name:
Group # and Member ID #:
24. Insurance Address and Phone #:
EMERGENCY INFORMATION
25. Local Friend or Relative not living with you:
26. Complete Address:
27. Phone Number:
GETTING TO KNOW YOU
28. Why did you select our office? :
29. Whom may we thank for referring you? :
30. Is another member of your family or relative a patient in our practice?:
FOR ALL PATIENTS

I authorize the doctor to perform any and all forms of treatment, medication, and therapy that may be indicated in connection with the dental care of the patient above and further authorize and consent that the doctor chooses and employs such assistants as he deems fit. I also understand that prior to treatment, a full explanation of the procedure(s) involved will be given by the doctor and/or his staff. I agree to pay for all services rendered by this office.

PRIVACY POLICY

I have chosen NOT to receive a copy of the privacy policy. I understand a copy is available at any time on the website www.TheAustinDentist.com

Patient's Parent's or Guardian's Signature
Date
MEDICAL HISTORY
Patient Name:
Nickname:
Age:
Name of Physician / and their specialty:
Most recent physical examination:
Purpose:
What is your estimate of your general health?
Excellent
Good
Fair
Poor
HAVE YOU EVER HAD THE FOLLOWING:
YES
NO
HAVE YOU EVER HAD THE FOLLOWING:
YES
NO
1. hospitalization for illness or injury
26. osteoporosis/osteopenia(taking bisphosphonates)
2. allergic reaction to
 
 
27. arthritis
aspirin, ibuprofen, acetaminophen
 
28. glaucoma
penicillin
 
29. contact lenses
erythromycin
 
30. head or neck injuries
codeine
 
31. epilepsy, convulsions (seizures)
local anesthetic
 
32. neurological problems (attention deficit disorder)
fluoride
 
33. viral infections and cold sores
metals (gold, stainless steel)
 
34. any lumps or swelling in the mouth
latex
 
35. hives, skin rash, hay fever
any other medications
36. venereal disease
3. heart problems or cardiac stent
37. hepatitis (type )
4. history of infective endocarditis
38. HIV / AIDS
5. artificial heart valve, repaired heart defect (PFO)
39. tumor, abnormal growth
6. pacemaker or implantable defibrillator
40. radiation therapy
7. artificial prosthesis (i.e. heart valve or joints)
41. chemotherapy
8. rheumatic or scarlet fever
42. emotional problems
9. high or low blood pressure
43. psychiatric treatment
10. a stroke (taking blood thinners)
44. antidepressant medication
11. anemia or other blood disorder
45. alcohol / drug dependency
12. prolonged bleeding due to a slight cut
ARE YOU:
13. emphysema, sarcoidosis
46. presently being treated for any other illness
14. tuberculosis
47. aware of any change in your general health
15. asthma
48. taking medication for weight management
16. breathing or sleep problems (i.e. snoring, sinus)
49. taking dietary supplements
17. kidney disease
50. often exhausted or fatigued
18. liver disease
51. subject to frequent headaches
19. jaundice
52. a smoker or smoked previously
20. thyroid, parathyroid disease, or calcium deficiency
53. considered a touchy person
21. hormone deficiency
54. often unhappy or depressed
22. high cholesterol or taking statin drugs
55. easily upset or irritated
23. diabetes (HbA1c= )
56. FEMALE: taking birth control pills
24. stomach or duodenal ulcer
57. FEMALE: pregnant
25. digestive disorders (i.e. gastric reflux)
58. MALE: prostate disorders
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.
List any medications, supplements, and or vitamins taken within the last two years
DRUG
PURPOSE
DRUG
PURPOSE
Ask for an additional sheet if you are taking more than 6 medications
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR MEDICATIONS YOU MAY BE TAKING.

DENTAL HISTORY
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
 
Previous Dentist
How long have you been a patient?
Months/Years
Date of most recent dental exam
Date of most recent x-rays
Date of most recent treatment (other than cleaning)
 
I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 mo.
not routinely
What is your immediate concern?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
 
YES
NO
PERSONAL HISTORY
1. Are you fearful of dental treatment? Scale of 1 (least) to 10 (most):
 
2. Have you ever had an unfavorable dental experience?
 
3. Have you ever had complications from past dental treatment?
 
4. Have you ever had trouble getting numb or reactions to local anesthetic?
 
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
 
6. Have you had any teeth removed?
 
SMILE CHARACTERISTICS
7. Is there anything about the appearance of your teeth that you would like to change?
 
8. Have you ever whitened (bleached) your teeth?
 
9. Have you ever felt uncomfortable or self-conscious about the appearance of your teeth?
 
10. Have you been disappointed with the appearance of previous dental work?
 
BITE AND JAW JOINT
11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, or popping)
 
12. Do you /would you have any problems chewing gum?
 
13. Do you/ would you have any problems with chewing bagels, baguettes, protein bars or other hard food?
 
14. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
 
15. Are your teeth crowding or developing spaces?
 
16. Do you have more than one bite and squeeze to make your teeth fit together?
 
17. Do you chew ice, bite your nails, use teeth to hold objects or have any other oral habits?
 
18. Do you clench your teeth in the daytime or make them sore?
 
19. Do you have any problems with sleep or wake up with an awareness of your teeth?
 
20. Do you wear or have you ever worn a bite appliance?
 
TOOTH STRUCTURE
21. Have you had any cavities within the past 3 years?
 
22. Does the amount of saliva in your mouth ever feel too little or do you have difficulty swallowing any food?
 
23. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
 
24. Are any teeth sensitive to hot, cold, biting, sweets or avoid brushing any part of your mouth?
 
25. Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth?
 
26. Have you ever broken teeth, chipped teeth or had a toothache or cracked filling?
 
27. Do you get food caught between any teeth?
 
GUM AND BONE
28. Do your gums bleed when brushing or flossing?.
 
29. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
 
30. Have you ever noticed an unpleasant taste or odor in your mouth?
 
31. Is there anyone with a history of periodontal disease in your family?
 
32. Have you ever experienced gum recession?
 
33. Are your teeth becoming loose on their own (without an injury), or do you have difficulty eating an apple?
 
34. Have you ever experienced a burning sensation in your mouth?
 
Our Financial Policy
Thank you for choosing us as your health care provider. We appreciate your trust in us and we appreciate the opportunity to serve you. As you know, our office and health care providers continue to struggle trying to get insurance companies to pay us in a timely manner. In order for us to provide the best service possible, we find ourselves having to make some hard insurance decisions. As a result, we implemented a new Financial Policy, which we require that you read, and sign prior to any treatment.
INSURANCE COVERAGE
Our office is happy to cooperate with patients who are covered by dental insurance. We ask that you familiarize yourself with your policy and be aware of any limitations that might exist. Having dental insurance means that you have an agreement with your insurance company regarding payment for dental procedures. There are varying dental levels that are available with a given insurance company. How well your plan pays will be based on what level plan of insurance you have purchased. We will file your primary insurance claim for you to help you obtain the reimbursement with which you are entitled. If your insurance company does not cover all costs, it will become your responsibility to make final payment.
PAYMENTS
Payment is due at time of service less your estimated insurance benefit. You may use cash, check, credit card or debit card to pay. Payment arrangements may be requested in cases of financial hardship through Care Credit. Except when financial arrangements have been made before hand, accounts that are 60 days past due will be billed 1.5% interest on the total unpaid balance. Accounts that are 90 days past due will be referred to a third-party collection agency. A fee will be assessed if account goes to collections.
INSURANCE PAYMENTS
Your insurance is a contract between you and your insurance company. We are not a party in this contract. Be assured, our office works diligently to obtain payment from your insurance company. However, if we file your insurance, and the claim has not been paid for any reason within 60 days, we require that you pay the balance using one of the approved payment methods without exception. In the event that your insurance pays us after that time, you will be reimbursed.
CONSENT FOR PROCEDURE
I certify that all of the medical and dental information I have provided is true and accurate to my knowledge and I have not eliminated any pertinent information. I consent to the performing of any dental examinations and treatment procedures agreed to be necessary or advisable, including anesthesia, nitrous oxide, or oral sedation, as indicated. A separate consent will be obtained for any surgical procedures. I understand that I will be informed of any treatment changes as they occur. I also understand that I am responsible for all fees associated with all procedures and all costs incurred in the collection of those fees, even if I am covered under a dental insurance policy.
EMERGENCY FIRST-TIME VISITS
Emergency first-time visits, we require payment in full of either cash or credit card prior to being seen.
MISSED / LATE-CANCELLEDAPPOINTMENTS
Our office requires a 24-hour notice for any rescheduling or cancellation of appointments. An appointment which is cancelled or failed without 24-business-hour notice will allow our office to charge a $75.00 broken appointment fee. Please note our business hours: Westlake - Monday/Wednesday 7:30am-3:30pm, Tuesday 8:00am-4:00pm, Thursday 8:00am-5:00pm, Friday 8:30am-12:00pm. Circle C - Monday 7:30am-4:30pm, Tuesday 9:00am-6:00pm, Wednesday/Thursday 8:00am-4:00pm, Friday 8:00am-2:30pm.
RETURNED CHECKS
Our bank charges us whenever a patient presents a check that does not have funds available. Therefore, we must charge you a $35.00 handling fee. Payment plus the handling fee will be due immediately, and we will request that future visits be paid with cash, credit or debit card. If in the event that you are sent to collections, for an outstanding bill, a collection fee will be assesed and levied. We welcome the opportunity to discuss any aspect of our financial policy. Please ask to speak to our office manager or assistant manager if you have any questions, comments, or concerns. We sincerely regret having to create such a policy and hope you understand our reasoning. We thank you for your support, and look forward to serving you in the future.
PATIENT AUTHORIZATION
I have read, understand, and agree to abide by the terms stipulated above. I request that payment of benefits be made to Matthew Horne, DDS. I hereby authorize the release of any information necessary to determine liability for payment and obtain reimbursement on any claim. This authorization shall remain valid until revoked by me in writing.
 
 
Patient Signature (or Parent of minor/Legal Guardian):

Draw your signature

Date:
 
Name of person completing form if other than patient:
Relation: