Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

The reason for your appointment *

Teeth Cleaning

Teeth Whitening

Porcelain Veneers

Fillings

Crowns

Invisalign

Bonding

Facial Rejuvenation

Dental Implants

Other

Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Spouse

First Name

Last Name

Phone Number

(###)

###

####

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.

I have read the above conditions of treatment and agree to their content.

Physician Phone Number

(###)

###

####

Date of your last medical examination

MM

DD

YYYY

Have you ever been treated for any of the following? *

Please check all that apply

High/low Blood Pressure

Stroke

Glaucoma

Asthma

Hay Fever

Emphysema

Sinus

Cough

Heart Disease

Heart Attack

Pacemaker

Artificial Heart

Valves

MVP/Heart Murmur

Rheumatic/Scarlet Fever

Prosthetic Limb/Joint

Surgical implant

AIDS

HIV +

Hepatitis (A)

Hepatitis (B)

Hepatitis (C)

Blood Transfusion

Diabetes

Prolonged Bleeding

Anemia

Arthritis

Leukemia/Cancer

Venereal Disease

Cold Sores

Fever Blisters

Canker Sores

Psychological Disorder

Thyroid Disease

Drug Addiction

Alcohol Addiction

Ulcers

Epilepsy/Seizures

Fainting Spells

Severe/Frequent Headaches

Then-Fen/Appetite

Suppressants

Are you allergic to any of the following?

Penicillin/Amoxicillin

Erythromycin

Keflex/Ceclor

Sulfa/Debacterol

Aspirin

Codeine

Darvon/Demerol

Percodan

Vicodin

Valium

Latex

Nitrous Oxide

Dental Anesthetic

Other

Are you pregnant? *

Yes

No

Due Date?

MM

DD

YYYY

Are you Nursing?

Yes

No

Are you taking Oral Contraceptives?

Yes

No

Are you taking Hormone Supplements?

Yes

No

Former Dentist's phone number

(###)

###

####

Are you currently experiencing any pain or discomfort?

Yes

No

Have you ever had an unfavorable dental experience?

Yes

No

Do your gums bleed when brushing your teeth?

Yes

No

Do you have an unpleasant odor or taste in your mouth?

Yes

No

Do you smoke?

Cigarettes

Pipe

Chewing Tobacco

Cigar

Marijuana

Are you satisfied with the appearance of your teeth and smile?

Yes

No

Have you ever had Periodontal Surgery/Periodontal Root Planning?

Yes

No

Have you ever had Oral Surgery

Yes

No

Have you ever had Orthodontic Treatment?

Yes

No

Do you clench/grind your teeth?

Yes

No

Do you have chronic headaches, or neck and shoulder pains?Have you ever experienced your jaw locking/clicking?

Yes

No

Have you ever experienced your jaw locking/clicking?

Yes

No

Does food catch between your teeth?

Yes (upper right)

Yes (upper left)

Yes (lower right)

Yes (lower left)

No

Which side do you favor when chewing?

Right

Left

Both

How often do you brush?

once a day

twice a day

every time you eat

Do you have a grating, clicking or popping in either or both jaws when you chew?

Do you have sensations or stuffiness, pressure or blockage, ringing, hissing or buzzing in your ears?

Do you ever feel dizzy or faint?

Is your jaw painful or locked when you wake up in the morning?

Do you consider yourself chronically fatigued?

Are you ever nauseated for no apparent reason?

Do your fingers sometimes go numb?

Check any area where you have pain or soreness.

Jaw Joints

Upper jaw or teeth

Back of head

Forehead

Lower jaw of teeth

Chewing muscles

Temples

Side of neck

Behind the eyes

Is it hard to move your jaw side-to-side, forward or backward?

Do you have difficulty chewing?

Do you have back teeth missing?

Have you had extensive dental crowns and bridgework?

Do you clench your teeth during the day?

Do you grind your teeth at night? (ask someone else)

Do you ever have a headache when you wake up?

Have you had whiplash injury?

Have you worn a cervical collar or had neck traction?

Have you ever had a blow to the chin, face or head?

Have you reached the point at which drugs no longer relieve your symptoms?

Does your jaw deviate to the left or right when you open wide?

When your mouth is wide open, can you insert three fingers into your mouth vertically?

QUESTIONAIRE COMPLETION *

I have completed this pre clinical questionnaire to the best of my knowledge

CONSENT FOR TREATMENT *

I hereby authorize Doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient/s dental needs. I also authorize Doctor to perform any and all form of treatment, medication, and therapy, that may be indicated in connection with me and further authorize and consent that Doctor choose and employ such assistance as he deems fit. I have been informed that he use of anesthetic agents and dental materials embodies a certain risk as well as other needed dental procedures, No guarantee, warranty, or assurance has been given to me that the treatment will be successful or to complete satisfaction. I agree to inform Doctor of any changes in my health, medication or change of address at the next appointment. Please feel free to obtain additional opinions regarding your dental needs.

Date *

MM

DD

YYYY

INSURANCE CONTRACT *

I understand that I am responsible for all fees, and that my dental insurance is a contract between me and my carrier, not between the carrier and the dentist. I understand that I will be charged for all dental treatment rendered. Dr. Laurence Rifkin agrees to issue a superbly as a courtesy to me and all payments shall go directly to me. I authorize release of any information relating to my claims.