Patient Information

Name*
Family Status
Address*
Birthdate*
If patient is a minor, give parent's or guardian's name:

Responsible Party / Billing Information (if someone other than the patient)

Responsible Party Name
Address
Birthdate

Insurance Information

Primary Insurance Information

Dental Insurance?
Insured's Name:
Birthdate
Address

Secondary Insurance Information

Dental Insurance?
Insured's Name:
Birthdate
Address

As a convenience to you, we will submit all claims directly to your insurance company. Your signature below will authorize direct remittance of insurance payments to this office, and to release information necessary to process the insurance claim. Your signature will also acknowledge financial responsibility for all charges, including all court costs and collection fees.

Acknowledgment of Financial Responsibility*

Medical History

What is your estimate of your general health?
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Are you taking any medications, pills or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Do you use tobacco?
Do you use controlled substances?
Women: Are you pregnant/trying to get pregnant?
Currently nursing?
Taking oral contraceptives?

Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic.)

Have you ever had any of the following? (Please check all that apply)

Have you ever been given antibiotics before dental treatment
Have you recently consumed alcohol?
Have you recently used recreational drugs?

Recreational use combined with local anesthesia may cause a life-threatening emergency.

Dental History

How would you rate the condition of your mouth?
Have you avoided regular dental care?
Do you feel you have active decay?
Do you experience frequent bad breath?
Do you feel you have gum disease?
Have you ever had gum treatments?
Have you had any teeth removed?
Do you have problems with your jaw joint (pain, sounds, limited opening, locking, or popping)?
Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Are you happy with the appearance of your teeth?
Would you like your teeth to be whiter?

Emergency Contact Information

Address

Privacy Practices

Please click on the link and read the following form.

I authorize Dr. Peterson and Dr. Sunde to perform any and all forms of dental treatment, medication, and therapy that may be indicated and further authorize and consent that Dr. Peterson and Dr. Sunde choose and employ such assistance as deemed appropriate. I also understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine. I further understand a 1% compounded finance charge (12% annually) will be added to any balance over 60 days. A fee may be charged for appointments cancelled without 24 hour notice.

Patient or Responsible Party
Date

Acknowledgment of Information Provided

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Name
Date
Cancel
Confirm