Patient Personal Information E-Form - Advanced Cosmetic Dentistry

Patient Personal Information Form

We are pleased to welcome you to our practice. Please print this form and fill it out as complete as possible. Due to HIPPA Privacy Laws, some sections cannot be filled out online. Please fax the completed form to (312) 263-7013 or you can bring it in with you to your scheduled appointment. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.
Patient Information
Name

First Name Middle Name Last Name
Today's Date

- Month - Day Year
Cell phone Number:

- Area Code Phone Number
Work Number:

- Area Code Phone Number
Home Number:

- Area Code Phone Number
SS#
Personal Email
example@example.com
Work Email (optional)
example@example.com

Home Address (No P.O. Box)

Street Address
Street Address Line 2
City	State
Zip Code	Country

Date of Birth

/ Month / Day Year
Age
Marital Status

Single Married Divorced Separated Partnered Minor
Sex

Male Female
Patient Employer/School
Patient Occupation
Employer/School Phone

- Area Code Phone Number

Employer/School Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

In case of emergency who should be notified?
Emergency contact
Phone Number

- Area Code Phone Number
Responsible Party

(If applicable)
Name of Responsible Party

First Name Middle Name Last Name
Date of Birth

/ Month / Day Year
Age
Relationship to Patient
Cell phone Number:

- Area Code Phone Number
Work Number:

- Area Code Phone Number
Home Number:

- Area Code Phone Number
SS#
Personal Email
example@example.com

Home Address (No P.O. Box)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Patient Authorization to Release Confidential Information

This authorization is optional, but MUST be signed in the office if you wish to release information to a specific person.
I, (Patient/Guardian) __________________________, hereby request and authorize Advanced Cosmetic & Implant Dentistry to disclose and provide copies of any and all clinical treatment records and information concerning my care, which is in the possession of Advanced Cosmetic & Implant Dentistry, to: (Name of Parent/Spouse/Person you wish to release records to) ___________________________________.

Relationship to patient: ______________________

These records include, but are not limited to: personal patient information, medical and dental histories, examination records, radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models, and or related materials. I expressly release from liability Advanced Cosmetic & Implant Dentistry, Dr Kevin Landers, and its employees from any and all liability arising from compliance with this request and disclosure of the requested information.

Patient/Guardian Signature: ___________________________________

Date __________
Patient Dental History
Reason for today's visit
Date of last dental care

- Month - Day Year
Date of last dental x-rays

- Month - Day Year
Former Dentist
Phone Number

- Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Check (✓) if you have had any problems with any of the following:

Bad breath Bleeding gums Clicking or popping jaw Grinding teeth Sensitivity to cold Sensitivity to hot Sensitivity to sweets Sensitivity when biting Loose teeth or broken fillings Periodontal treatment Sores or growths in your mouth
How often do you floss?
How often do you brush?
Patient Medical History
Physician's Name
Phone Number

- Area Code Phone Number
Date of last visit

- Month - Day Year
Have you ever used a bisphosphonate medication?

Yes No
Have you ever used a bisphosphonate medication? Common brand names are Fosomax, Actonel, Atelvia, Didronel, Boniva.

Yes No
Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Yes No
Have you had any serious illnesses or operations?

Yes No
If yes, describe
Have you ever had a blood transfusion?

Yes No
If yes, give approx. dates
(Women) Are you Nursing?

Yes No
Are you pregnant?

Yes No If yes, how far along in pregnancy? ________________

Check if you have/had any of the following:

	Yes	No
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cortisone Treatments
Cough, Persistent
Cough up Blood
Diebetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Hemophilia
Hepatitis

	Yes	No
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsilitis
Tuberculosis
Ulcer
Venereal Disease

Are you currently taking any medications?

Yes (list them below) No
List ALL medications you are currently taking:
Allergies?

Yes No
If yes, list all allergies:
Referral Section
Whom may we thank for referring you?
Why Did You Choose Us? (Check All That Apply)

Location Personal Recommendation Another Doctor's Office Dr Landers' Credentials Yelp Reviews Google Reviews YouTube Videos Our Before & After Images Article On Our Website Other: ______________________________
Websites Visited (Check all that apply)

American Academy of Cosmetic Dentistry CosmeticDentistChicago.com Other: ____________________________
If you found us on the Internet, please include the key words searched:
Summary
Check Off Items Below To Indicate The E-Forms You Filled Out On Our Website:

Dental Insurance E-Form (Faxed to: 312 263-7013) Medical Health History E-Form Dental Health History E-Form Cosmetic Questionnaire E-Form Cyber Consult *Send X-Rays & Images Personal Preferences Patient Communication E-Form Pain Management Patient Communication E-Form Bad Dental Experience Patient Communication E-Form Patient Satisfaction Survey E-Form
We appreciate your time expressing your past experiences and personal preferences. Your efforts will afford our team to ability to focus on your specific preferences and ultimately provide you with the best dental experience.

If you are a New Patient

You can fill out your new patient paper work now

1. Insurance Plan Information

2. Medical Health History E-Form

3. Dental History E-Form

If you have had a Bad Dental Experience, we strongly recommend you review

Bad Dental Experience Patient communication E-form

Recommended Reading:

1. Relaxation Techniques To Stay Calm During Dental Treatments

2. Self Help Strategies to overcome Dental Pain & Fear

3. Top 25 Dental Fears & Our Solutions “Facing Your Fears”

For Those Seeking Exceptional Care, please fill out:

Personal Preferences Patient Communication E-Form

For Those Seeking Cosmetic treatment, its “Very important” that you fill out:

Cosmetic Questionnaire

.

What Happens Next

It’s required that we keep your online information private and secure. Accordingly you will need to create and enter a 4-6 digit ID number on any E-form filled out on our site. Retain this 4-6-digit number as you will need to provide it to our scheduling coordinator. In turn, they will download your online information and save it to a new account hosted on our private secure server.

Your best option is to call our office in advance of your appointment date. This will allow extra time for Dr Landers to review the E-forms you took your time to fill out.

When you Call Please provide the Following E-form Information:

1. First & Last Name

2. The Names of E-Forms You Fill Out Online

3. The 4-6 Digit Number You Entered On The E-Forms.

We Will Use This ID Number To Attach Your E-Forms “Privately” To Your New Account At Our Office

Contact Us Today! 312-263-7823
To keep your information private and secure, please enter a 4-6 digit ID number of your choice below. Retain this 4-6 digit ID number as you will need to provide our office staff with that number during your appointment so we may retrieve your submission. You may also call our office beforehand and provide us with that number. *
Copyright Statement

Advanced Cosmetic & Implant Dentistry, has exclusive rights under U.S. and foreign copyright laws. Unless otherwise indicated, all materials on these pages are copyrighted by the Advanced Cosmetic & Implant Dentistry inc. All rights reserved. No part of these pages, either text or image may be used for any purpose other than personal use. Therefore, reproduction, modification, storage in a retrieval system or retransmission, in any form or by any means, electronic, mechanical, or otherwise, for reasons other than personal use, is strictly prohibited without prior written permission.

© Advanced Cosmetic & Implant Dentistry
ChicagosCosmeticDentist.com
312-263-7823
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Patient Personal Information Form

Patient Information

Responsible Party

Patient Authorization to Release Confidential Information

Patient Dental History

Patient Medical History

Referral Section

Summary