Morgan Glaze, D.M.D.
Curtis Henderson, D.D.S.
5895 Trinity Parkway, Suite 200
Centreville, VA 20120 703-818-1500
Patient Registration and Health History
Patient:
(First, M.I. Last)
Home Phone
Address
City
State
Zip
Sex:
M
F
Birth date
Social Security #
E-Mail
Whom may we thank for referring you to our practice?
Doctor Referral
Facebook
Google Ad
Insurance Referral
Internet Search
Personal Referral
Other
Dental History
What is the reason for your visit today?
Date of Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-Rays
How often do have dental examinations?
How often do you brush your teeth?
How often do you floss?
What other dental aids do you use? (Toothpick, mouth rinse, etc.)
Do you have any dental problems now?
YES
NO
If yes, please describe
Are any of your teeth sensitive to:
Hot or Cold?
YES
NO
Sweets?
YES
NO
Biting or chewing
YES
NO
Do your gums bleed or hurt?
YES
NO
Do you have any loose teeth?
YES
NO
Do you smoke/chew tobacco?
YES
NO
Do you:
Notice mouth odors or bad tastes?
YES
NO
Frequently get mouth sores?
YES
NO
Mouth breathe?
YES
NO
Have you experienced:
Clicking or popping of the jaw?
YES
NO
Pain? (joint, ear, side of face)
YES
NO
Have you ever had:
Orthodontic treatment?
YES
NO
Oral Surgery?
YES
NO
Gum treatment?
YES
NO
Bite adjustments?
YES
NO
Bite plate or splint?
YES
NO
Serious mouth injury?
YES
NO
Get food caught around teeth?
YES
NO
Clench or grind your teeth?
YES
NO
Have tired jaws?
YES
NO
Difficulty in opening or closing?
YES
NO
Difficulty in chewing?
YES
NO
Do you feel nervous about having dental treatment?
YES
NO
Have you ever had an upsetting dental experience?
YES
NO
Overall, how would you evaluate your past dental treatment and experiences?
Excellent
Good
Fair
Poor
Overall, how pleased are you with the appearance of your teeth and smile?
Extremely Pleased
Moderately Pleased
Satisfied
Dissatisfied
Medical History
1. Have you been under the care of a physician during the past two years?
YES
NO
If yes, for what?
Physician's name
Phone
Address
City
State
Zip
2. Are you taking any medication, including non-prescription, now?
If yes, for what?
3. List any allergies to drugs or substances
4. Indicate which of the following you have had, or have at present.
Yes No
Heart (Surgery, Disease, Attack)
Chest Pain
Congenital Heart Disease
Heart Murmur
High Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve
Rheumatic Fever
Arthritis/Rheumatism
Cortisone/Steroid Medicine
Stroke
Artificial Joints
Hepatitis, Jaundice, Liver Disease
Kidney Disease
Ulcers
Diabetes
Yes No
Asthma
Latex Sensitivity
Sinus Problems
Radiation Therapy
Chemotherapy
Cancer
Thyroid Problems
Venereal Disease
A.I.D.S. or HIV Infection
Prolonged Bleeding
Neurological disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
Psychiatric Care
Chemical Dependency
5. Do you have any disease, condition, or problem not listed?
If yes, please list
6.
Women:
Are you: Pregnant?
YES
NO
Nursing?
YES
NO
Taking birth control pills
YES
NO
In case of any emergency, contact
Phone
Referred by
Dental Insurance
Employed by
Occupation
Business address
Business phone
Single
Married
Divorced
Separated
Widowed
Spouse Name
Spouse Employed By
Occupation
Business Address
Business phone
Person Responsible for Account (or Guardian)
Relationship
Dental Insurance Company
Insured's Name
Insured's SS#
Insured's Date of Birth
Please sign below for the assignment of insurance benefits.
Signature
Date
Financial Arrangements
Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance. We accept cash, checks, and credit cards. We will be happy to help you process your insurance claim form. Returned checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1 1/2% per month
We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.
Our treatment recommendations are based upon achieving optimum dental health and not based upon what your insurance company allows.
While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect timely payment of your account If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.
If you have any questions about the above information or any uncertainty regarding insurance coverage, PLEASE don't hesitate to ask us. We are here to help you.
Signature
Date
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