Winning Smile - Patient Forms

Patient Forms

We are pleased to welcome you to our practice. Please take a few moments to fill out this form as completely as you can. If you have questions, we'll be glad to help you. Just email us here . All patient information is confidential. We look forward to assisting you in maintaining your dental health.

PATIENT INFORMATION

Last Name: First Name: M.I.
Social Security:
Address: City State: Zip
Sex: Male Female	Date o f Birth (M/D/Y):
Married Divorced Legally Separated Widow Single Student
Patient Employed by:	Occupation:
Business Address:
City State Zip
Business Phone:
Whom may we thank for referring you?
In case of emergency who should be notified? Phone:

PRIMARY INSURANCE

Dr. Knecht's office accepts most traditional and PPO dental plans. However, we are non-participating providers for the PPO plans. We will be happy to verify your insurance prior to your first visit. Who will be responsible for your account? Click here for yourself Last Name: First Name: M.I.
Relation to Patient:		Birthdate:
Social Security:
Address (if different from patient's): City State: Zip
Phone:
Person responsible employed by:
Occupation:
Business Address: Business Phone:
Insurance Company:
Contract #: Group #: Subscriber #:
Names of other dependents covered under this plan:

ADDITIONAL INSURANCE

Is the patient covered by additional insurance? Yes No
Subscriber Name:
Relation to Patient:		Birthdate:
Social Security:
Address (if different from patient's): City State: Zip
Phone:
Subscriber employed by:
Occupation:
Business Address: Business Phone:
Insurance Company:
Contract #: Group #: Subscriber #:
Names of other dependents covered under this plan:

DENTAL HISTORY

Reason for upcoming visit:

Former Dentist:

Address:

Date of last dental care:

Date of last dental X-rays:

Check if you have had problems with any of the following:

Bad breath	Grinding teeth	Sensitivity to hot
Bleeding gums	Loose teeth or broken fillings	Sensitivity to sweets
Clicking or popping jaw	Periodontal treatment	Sensitivity when biting
Food collection between teeth	Sensitivity to cold	Sores or growths in your mouth

How often do you floss?

How often do you brush?

MEDICAL HISTORY

Physician's Name:

Have you had any serious illnesses or operations? Yes No

If yes, give approximate dates:

Have you ever had a blood transfusion? Yes No

If yes, give approximate dates:

(Women) Are you pregnant? Yes No

Nursing? Yes No

Taking birth control pills? Yes No

Check if you have had problems with any of the following:

AIDS	Cortisone Treatments	Hepatitis	Rheumatic Fever
Anemia	Cough, Persistent	High Blood Pressure	Scarlet Fever
Arthritis, Rheumatism	Cough up Blood	HIV Positive	Shortness of Breath
Artificial Heart Valves	Diabetes	Jaw Pain	Skin Rash
Artificial Joints	Epilepsy	Kidney Disease	Stroke
Asthma	Fainting	Liver Disease	Swelling of Feet or Ankles
Back Problems	Glaucoma	Mitral Valve Prolapse	Thyroid Problems
Blood Disease	Headaches	Nervous Problems	Tobacco Habit
Cancer	Heart Murmur	Pacemaker	Tonsillitis
Chemical Dependency	Heart Problems	Psychiatric Care	Tuberculosis
Chemotherapy	Describe	Radiation Treatment	Ulcer
Circulatory Problems	Hemophilia	Respiratory Disease	Venereal Disease

Medications
List medications you are currently taking:

Allergies

Authorization

I authorize my insurance company to pay the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure payment of benefits.

I understand that I am financially responsible for all charges whether or not paid through the insurance provider.

Payment in full is due at time of treatment unless prior arrangements have been approved.

By clicking submit, I understand that I am bound by all of the above mentioned statements.

dentist@winningsmile.net