Pearl Dental San Jose

3005 Silver Creek Rd Ste 198, San Jose, CA 95121

408-622-8006

Today's Date:

Patient Information. As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your medical history in this questionnaire and there may be additional questions or forms concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Are you completing this form for another person, what is your relationship to that person?

Your Name:
Relationship:

Patient Information:

Last Name:
Middle Name:
First Name:
Email:
Date of Birth:
Mobile Phone (include area code)
Home Phone (include area code)
Work Phone (include area code)
Address:
City:
State:
Zip Code:
Mailing Address : If same as above address
Address:
City:
State:
Zip Code:
Sex:
Height:
Weight:
Occupation:
Employer Name, Address:
Marital Status:
Social Security Number:
Emergency Contact:
Relationship to Patient:
Patient Home Phone:
Patient Cell Phone:
Preferred Pharmacy:
Please tell us how you were referred to this office:

Physician Information. Please list all the physicians whose care you are currently under

Primary Care:
Telephone:
Address, City, State, Zip:
Specialist Physician:
Telephone:
Address, City, State, Zip:

Insurance Information. I certify that I or my dependants have insurance with the below listed companies and assign directly to XXXXXX Dental all insurance benefits. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Dental Insurer Company Name:
Name of Insured:
Their Soc. Sec. #:
Subscriber ID Number:
Group ID Number:
Insurance Phone Number:
Subscriber Date of Birth:

Medical Questions, general. Please indicate all that apply

Are you currently under the care of a physician?

Please Name:
Date of last physical exam:
If yes, what is the condition being treated?
If yes, what was the illness or problem?

If yes, please list all including vitamins, natural or herbals preparations and/or diet supplements or anything else the Dentist should be aware of:

Allergies. Please indicate all those you are or have been allergic to, and if yes please indicate your reaction

If YES, number of weeks
How much in a day?
Times per week:

Conditions, Diseases. Please indicate all that apply

AIDS or HIV infection
Alzheimer's Disease
Anemia
Angina
Arthritis / Gout
Artificial Heart Valve
Artificial Joint
Asthma
Atherosclerosis
AutoImmune Disease
Been told you Stop Breathing
Been told you Snore
Breathing Problems
Bruise Easily
Cancer
Cardiovascular Disease
Chemotherapy
Cold Sores / Fever Blisters
Congestive Heart Failure
Convulsions
Crohn's, Ulcerative Colitis
Depression
Diabetes
Dizziness
Drug Addiction
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Fainting Spells / Dizziness
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack
Heart Murmur
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Jaw Clicking, Locking
Jaw Joint Pain
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Other Heart (congenital) Defects
Osteoporosis
Pacemaker
Pain in Jaw Joints
Parathyroid Disease
Pneumonia
Psychiatric Care
Recent Weight loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Stroke
Teeth Grinding
Thyroid Disease
Tuberculosis
Tumors or Growths
Ulcers

Please list any and all Conditions or Diseases you may have, not listed here

*Both Doctor and Patient are encouraged to discuss any and all relevant Patient Health issues prior to treatment.

I hereby certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and staff will rely on this information for my treatment. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my Dentist nor any member of staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.


Signature of Patient

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Date:
Signature of Legal Guardian

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Date:

Privacy Practices Acknowledgment

I,
have received a copy of the Privacy Practices from 'Pearl Dental San Jose' dental practice.
Patient Name:
Phone:
Email:
Address:
City:
State:
Zip:
Patient's Signature:

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If same as Patient Signature

Date:
Witness's Name:
Date:
Witness's Signature:

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Consent for Services

You have the right as a patient, to be informed about your condition and the recommended dental, medical or diagnostic procedures to be used that you make the decision whether or not to undergo the procedure after knowing the risks involved. This disclosure is meant not to alarm you rather it is simply an effort to make you better informed so you may give or withhold your consent to a procedure.

I,
consent to be a patient of the dental practice 'Pearl Dental San Jose' and agree to radiographic and clinical examination. I also understand the following:

1. During the course of treatment, I may undergo procedures in all places of dentistry and medicine, including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, radiography, and saliva DNA testing.

Initials:

2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.

Initials:

3. No guarantee nor warranty can be made about treatment outcomes, restoration longevity, nor prognosis. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

Initials:

4. I will pay in advance any cost of treatment or insurance copayments according to the office's financial policy. I understand that even if an insurance pre-estimate is given or a procedure has been pre-approved, I am responsible for all costs that my insurance does not cover.

Initials:

5. My treatment plan may change over time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist and dental office staff.

Initials:

Financial Policy

Payment is due when services are rendered. For payment options, you may apply for a payment plan through Care Credit Dental Fee Plan, which must be arranged and approved in advance of your treatment appointment. As a courtesy to our patients who have dental insurance and medical insurance coverage, we will file your claim electronically. Your deductable and co-payment are due the day of service. Any amount exceeding your plan's annual maximum amount is due when service is rendered.

Please give our office at least 24 hour's notice to cancel or re-schedule an appointment.

A minimum fee of $50.00 will be charged for missed appointments. We appreciate your cooperation, Thank You.

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Date:

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