Amerifile.net

Welcome to Our Practice
Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL As a new patient, please fil out the information below to the best of your ability. PATIENT INFORMATION
CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAM Last Name First Name Middle Initial Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAM INSURANCE
Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Is patient covered by additional insurance? 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL PATIENT CONDITION
CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAM Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Is this condition get ing progressively worse? Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE FAMILY HISTORY
ONLY CALL 800.866.3453 TO PLACE YOUR ORDER Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL in any of your blood relatives:
Y CALL 800.866.3453 TO PLACE YOUR ORDER SAM PM556 • AmeriFile® • 800.866.3453 • amerifile.net Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL HEALTH HISTORY
Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Al information is strictly confidential. Do your gums bleed while brushing or flossing? Are your teeth sensitive to hot or cold liquids/foods? Do you bite your lips or cheeks frequently? Are your teeth sensitive to sweet or sour liquids/foods? Have you noticed any loosening of your teeth? CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Does food tend to become caught between your teeth? Y CALL 800.866.3453 TO PLACE YOUR ORDER SAM Do you have any sores or lumps in or near your mouth? Have you ever had periodontal treatment (gums)? Have you had any head, neck, or jaw injuries? Ever worn a bite plate or other appliance? Have you ever experienced any of the fol owing problems in your jaw: Have you ever had any difficult extractions in the past? Have you ever had any prolonged bleeding fol owing extractions? Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Have you ever received oral hygiene instructions regarding the care of your 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Have you ever taken Fosamax, Boniva, Actonel, or any cancer medications Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Have there been any changes in your general health within the past year? Have you taken Viagra, Revatio, Cialis, or Lavitra in the last 24 hours? Do you or have you used control ed substances? CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Are you now under the care of a physician? Do you have a persistent cough or throat clearing not associated with a Y CALL 800.866.3453 TO PLACE YOUR ORDER SAM Have you ever been hospitalized for any surgical operation or serious il ness? known il ness (lasting more than 3 weeks)? Do you have any disease, condition, or problem not listed here that you think Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Have you ever required a blood transfusion? Are you pregnant or think you may be pregnant? Please mark any of the fol owing that you Please mark any of the fol owing that you have or have had:
800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL are al ergic to, or have had reactions to:
Rheumatic heart disease or rheumatic fever Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL DER SAMPLE ONLatives, or sleeping pils Chest pain CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAM ORDER SAMPLE ONL Hepatitis, jaundice, or liver disease Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL MEDICATIONS
HEALTH HABITS
Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL List medications you are currently taking PLACE YOUR ORDER SAMPLE ONL Check which you use and how much: Check if your work exposes you to: CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE SIGNATURES
ONLY CALL 800.866.3453 TO PLACE YOUR ORDER I certify that I have insurance coverage with and assign directly to Dr. al insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financial y responsible for al charges whether or not paid by insurance. I authorize Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL the use of my signature on al insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent wil end when my current treatment plan is completed or one year from the date signed below.
CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Signature of Beneficiary, Guardian, or Personal Representative Y CALL 800.866.3453 TO PLACE YOUR ORDER SAM Please print name of Beneficiary, Guardian, or Personal Representative PM556 • AmeriFile® • 800.866.3453 • amerifile.net Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL Y CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL CALL 800.866.3453 TO PLACE YOUR ORDER SAMPLE ONL

Source: http://amerifile.net/pdf/pm556.pdf