Online Welcome Form Welcome to Modern Smiles Dental Care Thank you for choosing our office. At Modern Smiles we strive to build long-term relationships with our patients where we provide quality, consumer-friendly dental services utilizing the latest dental technology that the whole family can value and afford in a safe and happy environment. Your Name: (If Child, Parent or Guardian Name): Patient Information: Birthday: Sex: MaleFemaleOther Home Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: Email: How did you hear about our practice? Employer: Occupation: Spouse's Name (Or other parent/guardian)? Employer: Occupation: If patient is a student: Name of School/College: City & State: Full time or part time? Primary Insurance: Name of Insured: Subscriber's Birthday: Relationship to patient: SelfSpouseChild Address (if different from patient): Dental Insurance Co.: Subscriber ID #: Group, Contract or Local or union #: Secondary Insurance: Name of Insured: Subscriber's Birthday: Relationship to patient: SelfSpouseChild Address (if different from patient): Dental Insurance Co.: Subscriber ID #: Group, Contract or Local or union #: In Case of Emergency: Physician Name: Physician Phone Number: Someone we may contact: Phone #'s (home, work, cell): Dental History: Please check all that apply: ToothacheBroken filling or toothSensitivity to: ColdSensitivity to: HotSensitivity to: SweetsSensitivity to: ChewingFood catchesLoose TeethFloss breaks easily or hurtsBite or teeth haves hiftedOften bite cheeksFrequent dry mouthConcerned about breathUnhappy with previous dental workGums bleedGums tenderGrowths, soresColds ores, fever blistersCracked, chapped lipsBad taste in mouthSinus problemsMouth breathe — Difficulty breathing through noseDry or strained eyesShoulder, neck or headachesClench or grind teethJaw joint painClicking or popping of joint.Unable to open mouth wideJaw gets tired easily.Hold things between teeth (Pipe, pencil, nails, pins)Bite finger nailsUnusual habits with teethWore bracesPrevious gum treatmentPrevious bite treatmen Is there anything that bothers you (even just a little) about the appearance of your teeth or smile? Did your parents have difficulties with their teeth or dental treatments? Medical History: Have you been hospitalized for any reason? Please describe: Are you taking any medications or drugs (including nutritional supplements?) Please list: Are you taking or have ever taken Bisphosphonates? If yes, name of drug and how long taken: Are you allergic to penicillin, aspirin, local anesthetics, latex, sulfa, codeine, jewelry, metal, tetracycline, food allergies, other? Do you smoke? How much/day? Pregnant? Due date: Are you nursing?: Are you seeing a physician now or planning to see one for any reason? Please explain: Please check all that apply: DepressionPsychotic problemsSinus ProblemsPrevious injury to head or neckT8STDShinglesHeart problemDiabetesDigestive problem, ulcerShortness of breathHeart AttackHIV or AIDSThyroid diseaseSnoring, sleepapneaAngina, chestpainKidney problemGlaucomaNo energyHeart murmurLiver problem, jaundiceBleed or bruise easilyFainting or dizzyScarlet, Rheumatic feverCirrhosis, HepatitisStrokeUnexplained weight lossMitral valve prolapseCancer, Radiation, ChemotherapyEpilepsy or SeizuresChewing tobaccoIrregular heartbeatRespiratory problemParkinson'sDrug or alcohol addictionHigh or low blood pressureBloody, persistent coughAlzheimer's2 or more social drinks/dayPacemakerAsthma, EmphysemaBack problemAnxiety or nervous disorderArtificial joint, bones, valvesAnemiaHives, rashInsomniaNeurological disordersSickle cell diseaseDryeyesContact lensesOsteoporosis (list meds)ColitisHerpes/Fever Blisters Any other illnesses not checked above? Notice of Privacy Practices & Authorization: By signing this form, you consent that you have read our posted notice of Privacy Practices (HIPPA) and understand it completely. I understand that I am authorizing the release of my records to third party payers, other healthcare professionals or operations, or other entities as deemed necessary by this office. I understand that I (or said dependent) have insurance coverage that will be assigned to the office for billing and payment. I understand that I am financially responsible for all charges whether they are paid by insurance or not, as well as any additional collection costs for balances payable over 60 days. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize my insurance company to make payments directly to the dental office for benefits otherwise payable to me. I authorize the use of this signature on all insurance submissions/claims. I understand that appointment times are specifically scheduled for ideal patient care and that last-minute cancellations and no-shows are subject to a $50 per occurrence fee. I understand that after several missed appointments the doctor may dismiss me as a patient of the practice. I authorize Modern Smiles Dental Care to confirm my appointments via phone, email and text messaging confirmations. I further authorize being contacted about special services, events of new health information on behalf of the dental office via phone message, text message,and email. I have reviewed the information on this form, and it is accurate to the best of my knowledge. I will inform this office of any changes in my health status. I understand that dental treatment and local anesthesia entail risks such as bleeding, infection, nerve damage, or fracture of teeth or bone. I certify that the above information is complete and accurate to the best of my knowledge. Patient Signature (parent or guardian):