Health History Form Step 1 of 3 33% Your Name* First Last Email* Phone*Date of Birth* Age*SS#*Marital Status*Responsible PartyAddress* Street Address Address Line 2 City ZIP Code Employer*Employer Phone*Purpose of Visit*Who referred you to our office?Medical & Dental HistoryDate of Last Dental Exam Dentist's NamePhone # and AddressDate of Last Medical Exam Physician's NamePhone # and AddressHave you ever had or do you currently have any of the following (check box if yes) Asthma Diabetes Epilepsy Liver Problems Lung Problems Kidney Problems Rheumatic Fever Cardiovascular Disease High/Low Blood Pressure History of Fainting HIV Hepatitis A/B/C STDs Are you pregnant? Joint Replacements Prolonged Illness Any serious problem/abnormal bleeding associated with previous dental treatment?Have you had any adverse or allergic response to any drugs or anesthetic?Are you taking any medications at present time?Are you under medical care at present time?Any other illness past or present?Do you use controlled substances?Describe your general health in a few words.*Patient or Parent Signature*Today's Date* OFFICE POLICY ON PAYMENT TO SERVICE RENDERED This office files insurance as a courtesy to our patients. Additionally, we accept assignment of benefits from your insurance company so that we can receive payments directly. Ultimately, It Is the patient's responsibility to deal with his/her insurance company directly should any problems arise. Also, patients are responsible to pay their estimated co-payments directly to our office at the time of treatment. A patient's co-payment is quoted according to the information we receive from the insurance company. These co-payments are an estimate, not a guarantee. Insurance companies often will change treatment codes to provide for the minimum benefit payable. We do our best lo inform the patient of the estimated co-payment, taking all of the above information in to account. We can only guarantee our actual fee for any given service. We expect and appreciate greatly either our estimated co-payment or payment in full at the time of the visit. We do not normally extend credit and do not offer in-house financing, however no interest payment plans through a third party are available for qualified applicants. If, for some reason, our co-payment estimate is off, either send a statement for the remaining amount (statements will go out once a month until the account is paid in full) or we issue a credit on the account which can be used toward future work or refund the patient directly. Patients who keep an unpaid account balance over three months will be referred to an attorney. The patient will be responsible for any collection fees charged, including reasonable attorney fees(if applicable) by us or by the agency. * Yes I have read, fully understand, and agree to the terms of service at Burns Family Dentistry.Signature*Today's Date* CONSENT I give this practice/clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews. I have been informed that I may review the practice/clinic's Notice of Privacy Practices (for a more complete description of uses and disclosure,) before signing this consent. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice/clinic. I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice/clinic is not required to agree to the request. If the practice/clinic agrees to my requested restriction, they must follow the restriction(s). I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.Signature*Today's Date* Responsible Party (if patient under 18)