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Who will be responsible for your account?

Who will be responsible for your account? (If self, skip to next section)

Self Spouse Father Mother Other

Name

Birth Date / Age / S.S.#

Tel.

Address

City / State / Zip

Employer

Bus. Tel.

Spouse or other guarantor information (if different from above)

Name

Relation / S.S.#

Birth Date / Tel.

Address

City / State / Zip

Employer

Bus. Tel.

Primary Insurance Company

Insurance Type

Dental Medical

Employer

Bus. Address

City / State / Zip

Bus. Tel.

Plan

Ins. Co. Name

Address

City / State / Zip

Tel.

Group # / Name

Insured Party

Relation

Sex

Male Female

Birth Date

Address

City / State / Zip

Tel. / S.S. #

I.D. #

Secondary Insurance Company

Insurance Type

Dental Medical

Employer

Bus. Address

City / State / Zip

Bus. Tel.

Plan

Ins. Co. Name

Address

City / State / Zip

Tel.

Group # / Name

Insured Party

Relation

Sex

Male Female

Birth Date

Address

City / State / Zip

Tel. / S.S. #

I.D. #

Dental Information

Reason for today’s visit

Are you in pain?

Yes No

Medical History

Are you in good health?

Yes No

Height / Weight

Are you under the care of a physician?

Yes No

Have you had any illness, operation, or been hospitalized in the past five years?

Yes No

Please list any medications you are taking (including natural, herbal, homeopathic products)

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Medication #13

Medication #14

Medication #15

Medication #16

Are you now taking of have you taken

Blood thinners (Coumadin, Plavix, etc.)

Yes No

Any bone density medication or bisphosphonates (Aredia, Zometa, Fosamax, Actonel)

Yes No

Please list any other medication or antibiotic you are allergic to

Medication Allergy #1

Medication Allergy #2

Medication Allergy #3

Medication Allergy #4

Please list any allergies other than drug allergies

Please list any allergies other than drug allergies:

Below for women only

(Women note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.)

Is there a possibility of pregnancy?

Yes No

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Conclusion

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature of patient (Parent or Guardian if minor)

Click to Sign

Date:-------------

Fees and Payments

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

Signature of patient (Parent or Guardian if minor)

Click to Sign

Date:-------------

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Signature of patient (Parent or Guardian if minor)

Click to Sign

Date:-------------

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

Signature of patient (Parent or Guardian if minor)

Click to Sign

Date:-------------

truForm by PBHS

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Demographic Information

Patient Information

Who will be responsible for your account?

Spouse or other guarantor information (if different from above)

Insurance Information

Insurance Information

Primary Insurance Company

Secondary Insurance Company

Dental History

Dental Information

Please indicate any of the following problems by checking off the corresponding box

Medical History

Medical History

Do you have, or have you had, any of the following diseases, medical conditions, or procedures?

Medications and Allergies

Please list any medications you are taking (including natural, herbal, homeopathic products)

Are you now taking of have you taken

Are you allergic to or had a reaction to

Please list any other medication or antibiotic you are allergic to

Please list any allergies other than drug allergies

Below for women only

Conclusion

Conclusion

Click to Sign

Click to Sign

Click to Sign

Click to Sign

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Main Header

Demographic Information

Patient Information

Who will be responsible for your account?

Spouse or other guarantor information (if different from above)

Insurance Information

Insurance Information

Primary Insurance Company

Secondary Insurance Company

Dental History

Dental Information

Please indicate any of the following problems by checking off the corresponding box

Medical History

Medical History

Do you have, or have you had, any of the following diseases, medical conditions, or procedures?

Medications and Allergies

Please list any medications you are taking (including natural, herbal, homeopathic products)

Are you now taking of have you taken

Are you allergic to or had a reaction to

Please list any other medication or antibiotic you are allergic to

Please list any allergies other than drug allergies

Below for women only

Conclusion

Conclusion

Click to Sign

Click to Sign

Click to Sign

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.