Mon&Wed: 8:00am-5:00pmTue&Thu: 7:00am-4:00pmFri: 7:00am-1:00pm
6550 Sierra Drive Irving, TX 75039
Responsible Party (if someone other than the patient)
City, State, Zipcode
Responsible Party is also a Policy Holder for Patient
Primary insurance Policy Holder
Secondary insurance Policy Holder
I would like to receive correspondences via e-mail
Encore Launch Loyalty Discount PlanWord of Mouth
Walk In[checkbox pat_ReferrelSource "PPO Insurance"[checkbox pat_ReferrelSource "Online"]
Primary Insurance Information
Name of Insured
Relationship to Insured
Insured Social Security
Insured Dtae Of Birth
Secondary Insurance Information
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may
have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
Has anyone ever said you snore?
If yes, please explain:
Do your tissues ever bleed upon brushing or flossing?
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Women Are you: ?
Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
Recent Weight Loss
Hepatitis B or C
High Blood Pressure
Epilepsy or Seizures
Artificial Heart Valve
Hives or Rash
Sickle Cell Disease
Low Blood Pressure
Swelling of Limbs
Mitral Valve Prolapse
Cold Sores/Fever Blisters
Pain in Jaw Joints
Tumors or Growths
Congenital Heart Disorder
Have you ever had any serious illness not listed above?
If yes, please explain
What can we do to make you a patient for life?
If you had a magic wand and could change anything about your smile what would it be?
How loang has it been since your last dental visit?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN
SECTION A: PATIENT GIVING CONSENT (PARENT OR GUARDIAN IF PATIENT IS A MINOR)
SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of your Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Right To Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.