Section #1 PATIENT QUESTIONNAIRE
Terms & Condition *
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental service performed without prior financial arrangements, must be paid for in cash at the time services are performed. I understand that the fee estimate listed for this dental case can only be extended for a period of six months from the date of the patient's examination. In consideration of the professional services rendered to me, or at my request, by the Doctor and/or his staff, I agree to pay, therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be billed unless objected to, by me, in writing, within the time for payment thereof. Additionally, I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you, or your assigns, to telephone me at my home or at my work to discuss matters related to this form.
Section #2 MEDICAL HISTORY
Section #3 FOR WOMEN ONLY
Section #4 DENTAL HISTORY
Section #5 NEW PATIENT QUESTIONNAIRE
Please help us help you by filling out the following information. It is our intention to make your dental experience with us a comfortable and productive one. Your complete and specific information is essential to our communication and achieving the optimal results that are possible.
Goals relating to your teeth and smile
Section #6 Aesthetic Profile
You're lips? Your face?
If so, which procedures?
If not, please explain.
Section #7 TEMPOROMANDIBULAR JOINT DYSFUNCTION QUESTIONNAIRE
CONSENT FOR TREATMENT *