Marin Reconstructive Periodontics New Patient Form

Hamed H. Javadi, DDS, FRCD (C)

Brian Hollander, DDS, MS

WELCOME

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you. We look forward to working with you in maintaining your dental health.

First Name:

Last Name:

Initial:

Age:

Birthday:

Soc.Sec.#:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

Sex:

Male

Female

Status:

Single

Married

Widowed

Separated

Divorced

Patient Employed by:

Occupation:

Business Address:

Business Phone:

Business Email:

Notify in case of emergency:

Home Phone:

Cell Phone:

Business Phone:

Email:

PRIMARY INSURANCE

(Person Responsible for the Account Fill Out Below)

First Name:

Last Name:

Initial:

Relation to Patient:

Birthday:

Soc.Sec.#:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

Employed by:

Occupation:

Business Address:

Business Phone:

Business Email:

Insurance Company:

Insurance Phone:

Insurance Email:

Contract #:

Group #:

Subscriber #:

Name of other dependents under this plan:

ADDITIONAL INSURANCE

(If Patient is covered by Additional Insurance, Person Responsible for the Account Fill Out Below.)

First Name:

Last Name:

Initial:

Relation to Patient:

Birthday:

Soc.Sec.#:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

Employed by:

Occupation:

Business Address:

Business Phone:

Business Email:

Insurance Company:

Insurance Phone:

Insurance Email:

Contract #:

Group #:

Subscriber #:

Name of other dependents under this plan:

DENTAL HISTORY

What would you like us to do today?:

Are you in dental discomfort today?:

Former Dentist:

Address:

Dentist Email:

Phone:

Date of last dental care:

Date of last x-rays:

How often do you brush?:

Floss?:

How do you feel about the appearance of your teeth?:

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?

Yes

Other information about your dental health or previous treatment?:

MEDICAL HISTORY

Physician's name:

Date of last visit:

Phone:

Have you had any serious illness or operations?

Yes

If yes, describe:

Women: Are you pregnant?

Yes

Nursing?

Yes

Taking birth control?

Yes

Are you currently under physician care?

Yes

If yes, describe:

Have you ever had a blood transfusion?

Yes

If yes, give approximate dates:

Have you ever taken Fen-Phen/Redux?

Yes

If yes, describe:

If yes, give approximate dates:

Have you ever used a bisphosphonate medication? Brand names include Fosamax, Actonel, Didronel and Boniva.

Yes

Is patient currently taking any medications? If yes, list all:

Does patient have any drug allergies? If yes, list all:

AUTHORIZATION

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature:

Date:

PATIENT SCREENING FORM

Patient Name:

Do you/they have a fever or have you/they felt hot or feverish recently (14-21 days)?

Yes

Are you/they having shortness of breath or other difficulties breathing?

Yes

Do you/they have a cough?

Yes

Any other flu-like symptoms, such as gastrointestinal upset, headaches or fatigue?

Yes

Have you/they experienced recent loss of taste or smell?

Yes

Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes

Is your/their age over 60?

Yes

Do you/they have a heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes

Have you/they travled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Yes

Positive responses to any of thse would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

Name Validation