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Today’s Date:_____________ E-mail Address:_______________________________________________
Home Phone #________________ Cell Phone #________________Work Phone #________________ Ext #______
Name_________________________________ I prefer to called_____________________Birthdate_______________
Sex____Marital Status: S___M___W___D___ Spouse’s Name_________________Spouse’s Birthdate_____________
Spouse employed by_______________________________Spouse Soc.Sec.#_________________________________
Whom may we thank for referring you?_______________________________________________________________
Responsible Party Information:
Name of Responsible Party_____________________________ to Patient________________Birthdate____________
(If different than patient)Address_______________________________________City________________State___________Zip____________
Name of Dental Insurance Co.________________________________Group #_______________________________
Address to send claims to:___________________________________________________________________
(or provide copy of dental ins. card)Secondary Insurance:
Name of Dental Insurance Co._________________________________Group #_______________________________
Address to send claims to:____________________________________________________________________(or provide copy of dental ins. card)
Why have you come to the dentist today?____________________________________________________________
Are you in pain? ___Yes ___ No Do you require antibiotics before dental work? ___Yes ___No
Your current dental health is ___Good ___Fair ___Poor Do you floss daily? ___Yes ___No
Do you brush daily?___Yes ___No Do your gums ever bleed? ___Yes ___No
Have you ever had periodontal disease? ___Yes ___No Are your teeth sensitive to heat, cold, or anything else?____
Do you have mobility in your teeth? ___Yes ___No Previous/Present Dentist_____________City_________
Do you have popping or clicking in your jaw?___Yes ___No Last visit date______________
Do you grind or clench your teeth? ___Yes ___No
Would you like fresher breath? ___Yes ___No Would you like whiter teeth? ___Yes ___ No
Are you happy with the way your smile looks?
If not, what would you change?____________________________________________________________________
Physician’s Name__________________________ City_____________________Date of Last Physical_____________
Are you sensitive or allergic to any of the following?
(Please check if Yes)
Aspirin _____ Barbiturates_____Codeine _____ Latex _____ Sedatives _____
Dental Anesthetics _____ Jewelry/Metals _____
Any Antibiotics: E-Mycin____ Penicillin____ Sulfa____Tetracycline____Other____ Please List____________________
Have you had any joint replacements?
Are you currently taking any of the following blood thinners?
Y___N___ Coumadin, Warfarin, Plavix, Heparin,
Lovenox, Aggrenox, Aspirin If Yes, please circle the one you are taking
Have you ever had any of the following? (Please check if Yes)
___AIDS-HIV ___Anemia ___ Angina Please list any medications you are taking or give
___Arthritis ___Artificial Heart Valves ___Artificial Joints us a list to copy:
___Chest pains ___Circulatory problems ___Diabetes ________
___Emphysema ___Epilepsy ___Bleeding/clotting problems
___Fainting ___Hay fever/Allergies ___Heart Murmur _________________________________
___Heart Attack ___High Blood Pressure ___Hearing problems
___Hepatitis ___Headaches ___Kidney Disease _________________________________
___Leukemia ___Liver Disease ___Mental disorders
___Mitral Valve Prolapse ___Pacemaker ___Radiation treatment ______________________________
___Rheumatic Fever ___Sinus problems ___Stroke
___Tuberculosis ___Thyroid problem ___Ulcer
Do you suspect that you are pregnant? Y___N___ Pregnancy Due Date__Are you taking birth control pills? Y___N___
Are you under the care of a physician? ___________________For what conditions?___________________________
Is there anything else we should know about your medical history?_________________________________________
The above information is accurate and complete to the best of my knowledge.
I authorize the dentist to release any information including diagnosis and the records of treatment to my insurance
company and or health practitioners. I agree to be responsible for payment of all services rendered on my behalf or
Written Financial Policy
Thank you for choosing TUNNEL DENTAL CARE. Our primary mission is to deliver the best and
most comprehensive dental care available. An important part of the mission is making the cost of
optimal care as easy and manageable for our patients as possible by offering several payment
- Cash, Check, Visa, Mastercard or Discover Card
o Allow you to pay over time with NO INTEREST¹ (over 3-18 months)
o No annual fees or pre-payment penalties
Please note:TUNNEL DENTAL CARE requires payment on the date of service unless other arrangements havebeen made.
For patients with dental insurance we are happy to work with your carrier to maximize your benefitand directly bill them for you.³ We require payment of any deductible and/or copay on the date ofservice. This can also be taken care of with the “credit card authorization” form. If your insurance company has not made payment within 30 days of billing, the balance will become the responsibility of the patient.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistryyou want or need.
I understand this policy and agree to pay for all services rendered on my behalf or my dependents.
Date_______________ Signature ___________________________________________________
We would greatly appreciate a 48 hour notice from any patient (or patient representative) shouldthey need to reschedule or cancel an appointment. We reserve the right to apply a cancellation feeof $75 if this policy is not respected.
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