Welcome - Ultimate Smile Ft. Lauderdale

Welcome

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain oral health. Please take a moment to complete this confidential application and medical history information, so that we may better care for your dental needs. Your application will be submitted to us via email and will be ready for you to sign and complete with any missing information that was not included or that you were unsure of.

* Required fields

1. About You

*Today's Date:

*Social Security #:

*Birthday:

*Sex:

*Family status:

*Name:

*I like to be called:

*Home Address:

Apt./Condo #:

*City:

*State:

*Zip Code:

Drivers License #:

If you have Dental Insurance, please give the
Front Desk all necessary information when
returning this form.

2. Telephone

*Primary Phone:
*2nd Phone:
*Mobile Phone:
*Email Address:
When is the best time to reach you during the day?
Where?
Specific Day?
*Whom may we thank for referring you to our office?
Your Employer:
Employer Address:
Occupation:

911. Emergency

In the case of an emergency, is there someone who lives locally that we could contact?
*Name:
*Relationship:
*Work Number:
*Home Number:

3. Dental Information

*Date of last dental visit:
*Initial Concern:
*Reason for last dental visit:
*Are you having any pain at this time?:
*Is there anyone you would like here when we discuss treatment?:
*Rank why your teeth are important to you?:	Comfort Health Appearance Preservation
*Are you happy with your smile?:

*Have you ever had any of the following treatmant?:	Braces Oral Surgery Root Canal Therapy Periodontal Therapy
*Do your gums bleed when you brush your teeth?:
*Has any dental professional ever explained how to properly care for your teeth?:
*Have you ever experienced any problem with your jaw such as popping, clicking, or pain?:
*Do you clench or grind your teeth while awake or asleep?:
*Are there any other dental goals you would like to discuss?:
*Reason for leaving your last dentist:

I understand that responsiblity for payment for Dental Service provided in this office for myself or dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. I agree that if it becomes necessary for this office to take collections or legal action to obtain payment for services rendered to me, I will be responsible for the cost and attorney fees associated with the collection of outstanding monies due and payable to this office. I accept the responsiblity to pay the finace charges on all balances when applicable and understand that Ultimate Smile Ft. Lauderdale Offers assistance in claiming insurance benefits, but that I am ultimately responsible for the entire bill accrued. I understand that all insurance companies are contracted with the employer and the patient, not Ultimate Smile Ft. Lauderdale.

4. Medical History

*Name of Family Physician:

My current Physical Heath is:

Have you ever had any of the following?

Ulcers / Colitis

Rheumatic Fever / Artifical Valve / Murmer

Heart Disease / Defective Valves / Pacemaker

High or Low Blood Pressure

Kidney Problems

Diabetes

Tuberculosis

Malignancies (Cancer)

Asthma

Hay Fever / Allergies / Hives

Liver Disease or Jaundice

Thyroid Disorder

Epilepsy / Seizures / Fainting

Difficulties in Hearing or Vision

Alcohol/ Drug Use

Cigarettes

Stroke / TIA's

Sinus Trouble

Trouble with Extractions

Artificial Joints (Hip or Knee)

Excessive or Prolonged Bleeding Hemophilia

Anemia or Blood Disorder

Have you ever had adverse effects or reactions to:

Penicillin

Local Anesthetics (Novocaine, etc)

Latex

Any other drugs (if yes, please list)

*Are you now or recently been under the care of a physician?

If yes, Please list why.

*Have you ever had radiation treatment or been exposed to a considerable amount of radiation?

Extent
When

Current Medications:
Include Prescriptions and Over-The-Counter

Additional Comments / Hospitilizations:

	Are you Pregnant?
	If Yes, What Month?
	Are you Nursing
	Are you taking Birth Control Pills?

ALL INFORMATION IS TRUE AND COMPLETE
TO THE BEST OF MY KNOWLEDGE

* Consent:

The undersigned hereby authorizes Dr. Heider and Ultimate Smile to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make a through diagnosis of the patient's dental needs. I also authorize Dr. Heider and Ultimate Smile to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with myself or patient and further authorize and consent that Dr. Heider and Ultimate Smile choose and employ assistance. I also understand use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for dental service provided in this office for myself or my dependents is mine; due and payable at the time services are rendered unless financial arrangements have been made. In addition, I grant Dr. Heider and Ultimate Smile the right to release health information obtained from me, and information about my dental treatment to third party payers, and/or health practitioners.

Thank you for filling out this form completely. It will enable us to help you more effectively. If you have questions at any time, please ask us. We are happy to help. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.