<p> DENTAL HISTORY</p><p>Do your gums bleed?  Y  N Do you have pain, ringing, or popping in or near your ears?  Y  N Do you have pain when chewing or biting?  Y  N Have you experienced any growth or sore spots in your mouth?  Y  N Have you ever had: Orthodontics (Braces)?  Y  N Local Anesthetic?  Y  N Difficult extractions?  Y  N Prolonged bleeding?  Y  N Gum disease?  Y  N A bad dental experience?  Y  N Are you happy with the color of your teeth?  Y  N Have you visited our website?  Y  N Were you satisfied with your previous dental care?  Y  N</p><p>When was your last dental visit? :______When was your last complete set of dental radiographs taken? :______What can we do to assure a good dental experience here? :______What problems are you having with your mouth? :______Who referred you to our office? :______</p><p>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 patients) health. It is my responsibility to inform the dental office of any changes in medical status. CONSENT FOR TREATMENT</p><p>1)The patient or his representative recognizing the need for care, consents to all services as ordered by our office, including medical treatment and examination, laboratory and x-ray procedures, minor or emergency surgical treatment, or other treatment rendered under specific instructions of the doctor. ______</p><p>2) I hereby authorize Bluth Family Dental to furnish information to insurance carriers concerning my dental needs and treatment and I hereby assign to Bluth Family Dental all payments for services rendered to my dependants or myself. ______</p><p>3) I understand that a minimum 24 hours notice is required for cancellation of appointments. A broken appointment fee may be charged to my account, and is payable by me if 24 hrs. notice is not given. ______</p><p> Not all of the doctors participate in all of the dental plans. To insure you are covered properly, you MUST supply all necessary insurance information to our office prior to your appointment.</p><p> I HAVE RECEIVED A COPY OF THIS OFFICE’S NOTICE OF PRIVACY PRACTICES.</p><p>______Financially responsible party Date</p>