Patient Forms
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Thank you for trusting us with your dental care. We are committed to provide you with the finest care available. If you have any questions please do not hesitate to ask us. Patient Name: Account #: DOB: PATIENT INFORMATION Name Birthdate Cell Phone Address City State Zip Gender ☐M ☐F ☐Minor If yes, Guardian’s Name E-mail Home Phone ☐ Join our mailing list for news, announcements and special promotions. Employer/School Employer/School Phone Employer/School Address City State Zip Spouse/Guardian Employer Cell Phone Emergency Contact Cell Phone ☐ I authorize Cunning Dental Group to send me text messages related to my dental health (standard text message fees may apply). RESPONSIBLE PARTY Name of Person Responsible for this Account Relationship to Patient Address City State Zip Driver’s License # Birthdate Employer Social Security # Cell Phone Work Phone Home Phone Currently a patient in our office? ☐Yes ☐No E-mail INSURANCE INFORMATION Name of Insured Relationship to Patient Birthdate Social Security # Date Employed Employer Work Phone Employer Address City State Zip Insurance Company Member ID # Union or Local # Cunning Dental Group (877)41-SMILE PATIENT INFORMATION FORM 0619 Page 1 of 2 ADDITIONAL INSURANCE Name of Insured Relationship to Patient Birthdate Social Security # Date Employed Employer Work Phone Employer Address City State Zip Insurance Company Member ID# Union or Local # DENTAL HISTORY Reason for today’s visit Concern regarding smile/teeth: Are you here for a second opinion? ☐ Yes. Reason: ☐ No Former Dentist Date of last dental visit Dentist’s Address City State Zip Check (☒) if you have had problems with any of the following: ☐ Bad breath ☐ Bleeding gums ☐ Clicking or popping jaw ☐ Food collection between the teeth ☐ Grinding teeth ☐ Loose teeth or broken fillings ☐ Periodontal treatment ☐ Sores or growths in your mouth ☐ Sensitivity to hot ☐ Sensitivity to sweets ☐ Sensitivity when biting ☐ Sensitivity to cold How often do you floss? How often do you brush? Do you feel you require? ☐ Nitrous Oxide ☐ IV Conscious Sedation ☐ General Anesthesia (Laughing Gas) (Sleep Dentistry) (with an Anesthesiologist) REFERRAL INFORMATION INTERNET RADIO TELEVISION OTHER ☐ Facebook ☐ KEIB Patriot 1150 AM ☐ ABC 7 ☐ Dentist Referral, ☐ Google ☐ KFI 640 AM ☐ FOX 11 please provide name ☐ Instagram ☐ KLAC Sports 570 AM ☐ TV Unknown ☐ Employee Referral, ☐ Our Website ☐ KNX 1070 AM please provide name ☐ Yelp ☐ KOGO San Diego ☐ Insurance Plan ☐ Radio Unknown ☐ Patient Referral, please provide name ☐ Print ☐ Unknown ☐ Valpak Cunning Dental Group (877)41-SMILE PATIENT INFORMATION FORM 0619 Page 2 of 2 Patient Name: Account #: DOB: MEDICAL HISTORY Name of physician/their specialty: Most recent physical examination: Purpose: Name of pharmacy/phone/address: Age: Height: Weight: Today’s BP: O2Sat: YES NO 1. ☐ ☐ Hospitalization for illness or injury (if yes, explain) 2. ☐ ☐ Heart problems 3. ☐ ☐ Cardiac stent within the last six months 4. ☐ ☐ History of Endocarditis (heart infection) 5. ☐ ☐ Artificial heart valve, repaired heart defect (PFO) 6. ☐ ☐ Pacemaker or implantable defibrillator 7. ☐ ☐ Orthopedic implant (joint replacement) 8. ☐ ☐ High blood pressure 9. ☐ ☐ Low blood pressure 10. ☐ ☐ A stroke (taking blood thinners) 11. ☐ ☐ Anemia or other blood disorder 12. ☐ ☐ Prolonged bleeding due to a slight cut (INR>____________) 13. ☐ ☐ Emphysema, shortness of breath, sarcoidosis 14. ☐ ☐ Tuberculosis, measles, chicken pox 15. ☐ ☐ Asthma 16. ☐ ☐ Breathing or sleep problems (i.e. sleep apnea, snoring, sinus) 17. ☐ ☐ Kidney disease 18. ☐ ☐ On dialysis 19. ☐ ☐ Liver disease 20. ☐ ☐ Thyroid, parathyroid disease, or calcium deficiency 21. ☐ ☐ Hormone deficiency 22. ☐ ☐ High cholesterol or taking statin drugs 23. ☐ ☐ Diabetes (HbA1c) A1C______________________________ 24. ☐ ☐ Stomach or duodenal ulcer 25. ☐ ☐ Digestive disorders (i.e. celiac disease, gastric reflux) 26. ☐ ☐ Gastric bypass/sleeve 27. ☐ ☐ Osteoporosis / osteopenia (i.e. taking bisphosphonates) ☐ IV ☐ Pills How long ago? ___________ For how long? _____________ 28. ☐ ☐ Arthritis 29. ☐ ☐ Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma) 30. ☐ ☐ Head or neck injury 31. ☐ ☐ Epilepsy, convulsions (seizures) 32. ☐ ☐ Neurologic disorders (ADD, ADHD, prion disease) 33. ☐ ☐ Cold sores 34. ☐ ☐ Any lumps or swelling in the mouth 35. ☐ ☐ Hives, skin rash, hay fever 36. ☐ ☐ STI / STD / HPV 37. ☐ ☐ Hepatitis (type A, B or C) Cunning Dental Group (877)41-SMILE MEDICAL HISTORY 0719 Page 1 of 2 YES NO 38. ☐ ☐ HIV / AIDS (T-cell (CD4) count ____________) 39. ☐ ☐ Tumor, abnormal growth, cancer Type ___________________________ 40. ☐ ☐ Radiation therapy. Area ___________ When____________ Frequency______________ 41. ☐ ☐ Chemotherapy, immunosuppressive medication 42. ☐ ☐ Emotional difficulties 43. ☐ ☐ Psychiatric treatment 44. ☐ ☐ Antidepressant medication 45. ☐ ☐ Alcohol / Recreational drug use / Marijuana Are you? 46. ☐ ☐ Presently being treated for any other illness If yes, what is it? ___________________________________ 47. ☐ ☐ Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, diarrhea) 48. ☐ ☐ Taking medications for weight management 49. ☐ ☐ Taking dietary supplements 50. ☐ ☐ Often exhausted or fatigued 51. ☐ ☐ Experiencing frequent headaches 52. ☐ ☐ A smoker/vaper. How many/much per day? _____________ 53. ☐ ☐ Chewing tobacco 54. ☐ ☐ Taking birth control pills 55. ☐ ☐ Currently pregnant 56. ☐ ☐ Taking medication for erectile dysfunction (i.e. Viagra, Cialis, or other medication) 57. ☐ ☐ Taking blood thinners An allergic reaction to: Aspirin Tetracycline Ibuprofen (Advil/Motrin) Sulfa Acetaminophen (Tylenol) Local Anesthetic Codeine Fluoride Penicillin Metals (Nickel, Gold, Silver) Erythromycin Latex Other __________________________________________ Is there any other medical issue we should be aware of? List all medications, supplements, and or vitamins taken currently (use additional pages if necessary). Drug Purpose Drug Purpose Signature of Patient or Legal Representative Date Doctor’s Signature Date Changes in health since last seen? _______________________________ Patient’s Initials: ___________________ Date: ______________________ Dr.’s Initials: _______________________ Date: ___________________ BP Reading: ___________________________________________________ Changes in health since last seen? _______________________________ Patient’s Initials: ___________________ Date: ______________________ Dr.’s Initials: _______________________ Date: ___________________ BP Reading: ___________________________________________________ PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING. Cunning Dental Group (877)41-SMILE MEDICAL HISTORY 0719 Page 2 of 2 Patient Name: Account #: DOB: HIPAA / INSURANCE RELEASE / NOTICE OF PATIENT RESPONSIBILITY HIPAA: Consent of Disclosure I hereby give consent to CUNNING DENTAL GROUP (CDG) to use and disclose my protected health information for the purpose of treatment, payment and health care operations. You may cancel this consent at any time. Your cancellation must be in writing, signed by you or on your behalf, and it will only be effective when we actually receive it. You have the right to request restriction on the usage and disclosure of your protected health information for the purpose of treatment, payment or health care operations. We are not required to grant your request, however, if we do, the restriction will be obligatory to us. Our posted privacy policy proviDes more detailed information about the usage and disclosure of your protected health information. You have the right to review our posted privacy policy before you sign this consent. We reserve the right to amend the terms of our Posted Privacy Policy. You may obtain a copy of the current policy by asking the front office staff or by calling (909) 624-9087. Acknowledgement of Receipt of Privacy Practice Notice I acknowledge that I have received a Notice of Privacy Practices from Cunning Dental Group. Signature of Patient or Legal Representative: Date: Insurance Release Form I hereby instruct and direct my insurance company to pay Cunning Dental Group by check made out and mailed to: Ronald Cunning DDS Inc., dba Cunning Dental Group, 9595 Central Ave, Montclair, CA 91763. If my current policy prohibits direct payment to the doctor, I hereby also instruct and direct my insurer to make out the check to me and mail it to the address listed above for the professional or dental expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee. I have agreed to pay in a current manner any balance of said professional service charges over and above this insurance payment. A photocopy of this assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case. Signature of Patient or Legal Representative: Date: Cunning Dental Group (877)41-SMILE HIPAA/INSURANCE RELEASE/ NOTICE OF PATIENT RESPONSIBILITY 0719 Page 1 of 2 Notice of Patient Responsibility I understand that I am personally responsible for the cost of my dental care. I agree to pay for any dental work rendered by the office, if for any reason whatsoever my insurance coverage