ROSEROOT DENTAL - Patient Forms

Home

About us

Cosmetic Dentistry

Services

Invisalign

Testimonials

Insurance Plans

Financing

Patient Forms

PATIENT FORMS
	To View or Print Forms please select from the options below: Financial Policy Form - PDF Format Financial Policy Form - MS Word Format Truth In Lending Form - PDF Format Truth In Lending Form - MS Word Format

Patient Information
Today's Date
(Patient) Full Name
First Name Middle Name Last Name
(Patient) Birth Date
Month Day Year
I Prefer to be Called:
(Patient) Gender

Male Female
(Patient) Age:
(Patient) Social Security #
(Patient) Driver License #
Martial Status

Single Married Divorced Widowed Seperated

Patient Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

(Patient) Home Phone #
- Area Code Phone Number
(Patient) Cell Phone #
- Area Code Phone Number
(Patient) Work #
- Area Code Phone Number
(Patient) E-mail
Do you prefer text message or e-mail confirmation?
Where and when are best times to reach you?
Other family members seen by us:
Whom may we thank for referring you?
(Patient) Employer
How long there?
Occupation

(Patient) Employer's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Neighbor/Relative not living with you
(Neighbor/Relative) Full Name
First Name Last Name
(Neighbor/Relative) Relation
(Neighbor/Relative) Home #
- Area Code Phone Number
(Neighbor/Relative) Work #
- Area Code Phone Number

(Neighbor/Relative) Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Spouse Information
(Spouse) Full Name
First Name Last Name
(Spouse) Birth Date
Month Day Year
(Spouse) Social Security #
(Spouse) Employer
(Spouse) Work #
- Area Code Phone Number
(Spouse) Drivers License #
Insurance Information
(Primary Insurance)
Dental Coverage?

Yes No
Orthodontic Coverage?

Yes No
Medical Coverage?

Yes No
(Primary) Insurance Co. Name
(Primary) Insurance Phone #
- Area Code Phone Number
(Primary) Member Identification #
(Primary) Group/Plan/Local/Policy #

(Primary) Insurance Co. Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

(Primary) Insured's Full Name
First Name Last Name
(Primary) Insured's Social Security #
(Primary) Insured's Date of Birth
Month Day Year
(Primary) Relation to Insured
(Primary) Insured's Employer

(Primary) Insured's Employer Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Insurance Information
(Secondary Insurance)
Dental Coverage?

Yes No
Orthodontic Coverage?

Yes No
Medical Coverage?

Yes No
(Secondary) Insurance Co. Name
(Secondary) Insurance Phone #
- Area Code Phone Number
(Secondary) Member Identification #
(Secondary) Group/Plan/Local/Policy #

(Secondary) Insurance Co. Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

(Secondary) Insured's Full Name
First Name Last Name
(Secondary) Insured's Social Security #
(Secondary) Insured's Date of Birth
Month Day Year
(Secondary) Relation to Insured
(Secondary) Insured's Employer

(Secondary) Insured's Employer Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Dental History
Why have you come to the dentist today?
Are you currently in pain?

Yes No
Do you require antibiotics before dental treatment?

Yes No
Your current dental health is:

Good Fair Poor
Do you floss daily?

Yes No
Do you brush daily?

Yes No
Type of bristles on your toothbrush:

Hard Medium Soft
Do your gums ever bleed?

Yes No
Do your gums ever itch?

Yes No
Have you ever had periodontal disease?

Yes No
Are your teeth sensitive to heat, cold, or anything else?

Yes No
Do you have mobility in your teeth?

Yes No
Do you still have wisdom teeth?

Yes No
Date of last visit with a dentist
Would you like fresher breath

Yes No
Would you like whiter teeth?

Yes No
Are you happy with the way your smile looks?

Yes No
What would you change?
Medical History
Do you have a personal physician?

Yes No
Physician's Name

Physician's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Physician's Phone #
- Area Code Phone Number
Date of Last Visit
Your current physical health is

Good Fair Poor
Are you currently under the care of a physician

Yes No
Please Explain
Do you smoke or use tobacco in any other form?

Yes No
Have you ever taken Phen-Fen, Redux, or Pondimin?

Yes No
Are you taking birth control pills?

Yes No
Are you pregnant?

Yes No Unsure
Week #
Are you nursing?

Yes No
Do you or have you experienced the following?

Abnormal Bleeding Alcohol Abuse Anemia Arthritis Artificial Bones/Joints Artificial Valves Asthma Blood Transfusion Cancer Chemotherapy Chicken Pox Colitis Congenital Heart Defect Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Hospitalized (Ever) Fainting Spells Fever Blisters Glaucoma Hay Fever Headaches Heart Attack Heart Murmur Heart Surgery Hemophilia Hepatitis High Blood Pressure HIV+/ AIDS Kidney Problems Liver Disease Low Blood Pressure Lupus Mitral Valve Prolapse Pacemaker Persistent Cough Psychiatric Problems Radiation Treatment Rheumatic Fever Scarlet Fever Seizures Shingles Sickle Cell Disease Sinus Problems Steroid Therapy Stroke Thyroid Problems Tonsillitis Tuberculosis(TB) Ulcers Venereal Disease
Please list any serious medical condition(s) that you have experienced
Are you taking any prescriptions/ over the counter drugs?

Yes No
Please list each one
Are you allergic to any of the following?

Aspirin Barbiturates Codeine Dental Anesthetics Erythromycin Jewelry/ Metals Latex Penicillin Sedatives Sulfa Drugs Tetracycline Other No Known Allergies
Please list anything additional that causes allergic reactions
Authorization
I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover.
Signature:*
Please type your full name
Date:*
Should be Empty:

• Make Your Appointment Now •

ROSEROOT DENTAL • GENERAL • COSMETIC • IMPLANT • GENTLE DENTISTRY
Golf-River Professional Bldg. 1455 E. Golf Rd. Suite 216 Des Plaines, IL 60016
Phone: 847.699.3370 Fax: 847.699.0383