Dental Health Record Template
I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Corey L. Plaster, DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.
| Yes | No | |
|---|---|---|
| Do you require antibiotics before dental treatment? |  | |
| Are you currently in pain? | | |
| Do you now or have you had any pain/discomfort in your jaw joint? | | |
| Are you aware of clenching or grinding your teeth? | | |
| Does it hurt when you chew or open wide to take a bite? | | |
| Do you have any jaw symptoms or headaches upon waking up in the morning? | | |
| Do you have pain in the face, cheeks, jaw, joints, throat or temples? | | |
| Do you like your smile? | | |
| Is there anything you would like to change about your smile? | | |
| Are you happy with the color of your teeth? | | |
| Have you ever had gum disease? | | |
| Do your gums bleed? | | |
| Have you ever had a deep cleaning or scaling and root planing? | |
| Yes | No | |
|---|---|---|
| Are your teeth sensitive to heat, cold or anything else? | | |
| Do you take fluoride supplements? | | |
| Have you ever had a serious/difficult problem with any previous dental work? | | |
| Have you ever had any unfavorable dental experiences? | | |
| Are you apprehensive about dental treatment? | | |
| Do you gag easily? | |
I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Corey L. Plaster, DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
Our Dental Health Record Template is designed to gather important health information and produce a secure PDF document for each and every patient. You can then download or print the PDFs out for your records, or automatically send a copy to the patient via email.
Have patients fill out their information on a computer or tablet using an online Dental Health Record Form, then use PDF Editor to easily format the data into a polished PDF document for the patient’s file. Cut out pesky paperwork and enjoy the benefits of a smoother patient intake process with our Dental Health Record Template.
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These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.