Forms & Insurance - Chehalis WA Dentist
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Child Information
First Name:
Last Name:
Middle Initial:
Birthdate:
Sex: Male Female
Mailing Address:
City:
State:
Zip:
Father or Guardian:
Father Mailing Address:
Father City:
Father State:
Father Zip:
Father Home Phone: - -
Father Cell Phone: - -
Father Employer:
Father Work Phone: - -
Mother or Guardian:
Mother Mailing Address:
Mother City:
Mother State:
Mother Zip:
Mother Home Phone: - -
Mother Cell Phone: - -
Mother Employer:
Mother Work Phone: - -
Who will be responsible
for this account:


If you have dental insurance, please
provide the following information:
Primary Insurance:
Subscriber's Name:
Subscriber's Birthdate:
Relation to patient:
ID#:
Insurance Address:
City:
State:
Zip:
Phone: - -
Group or Plan #:


Is Patient Covered By Additional Dental Insurance?
Secondary Insurance:
Subscriber's Name:
Subscriber's Birthdate:
Relation to patient:
ID#:
Insurance Address:
City:
State:
Zip:
Phone: - -
Group or Plan #:


Emergency Contact:
Who should be notified:
Phone: - -
Dental History

Reason for today's visit:

How often do you floss:
How often do you brush?
Former Dentist:
City/State:
Date of last dental visit:
Date of last dentist X-rays:
Please check "yes" or "no" to indicate if you have had any of the following:
Bad breath Yes No
Bleeding gums Yes No
Blisters on lips or mouth Yes No
Burning sensation on tongue Yes No
Chew on one side of mouth Yes No
Cigarette, pipe, cigar smoking, or chewing tobacco Yes No
Clicking or popping jaw Yes No
Dry mouth Yes No
Fingernail biting Yes No
Food collection between teeth Yes No
Foreign objects/piercing Yes No
Grinding teeth Yes No
Gums swollen or tender Yes No
Jaw pain or tiredness Yes No
Loose teeth or broken filling Yes No
Lip or cheek biting Yes No
Mouth breathing Yes No
Mouth pain, brushing Yes No
Orthodontic treatment Yes No
If yes, date:
Pain around ear Yes No
Past facial/jaw trauma Yes No
Periodontal treatment Yes No
If yes, date:
Sensitivity to cold Yes No
Sensitivity to heat Yes No
Sensitivity to sweets Yes No
Sensitivity when biting Yes No
Sores or growths in mouth Yes No
Wear night guard Yes No
Medical History
Physician's Name
Date of Last Visit
Have you had any serious illnesses or operations in the last 3 years? Yes No
If yes, describe
Have you ever had a blood transfusion? Yes No
If yes, give approximate date
Do you use a CPAP machine? Yes No
(Women) Are you pregnant? Yes No
(Women) Are you nursing? Yes No
(Women) Are you taking birth control pills? Yes No
Check the boxes below if you have or have had any of the following:
Acid reflux
Anemia
Arthritis, rheumatism
Artificial heart valves
Artificial joints
If yes, date:
If yes, name of surgeon:
Asthma
Back problems
Blood disease
Cancer
If yes, type:
Chemical dependency
Chemotherapy
Chest pain
Cortisone treatments
Cough
Diabetes
Dizziness
Epilepsy
Fainting
Glaucoma
Headaches
Heart murmur
Heart problems
Hemophilia
Hepatitis
High blood pressure
High cholesterol
HIV/AIDS
Jaw pain
Kidney disease
Liver disease
Mitral valve prolapse
Pacemaker
Radiation treatment
Respiratory disease
Rheumatic fever
Shortness of breath
Sinus problems
Skin rash
Stroke
Swelling of feet or ankles
Thyroid problems
Tonsilitis
Tuberculosis
Ulcer
Please list any other disease or medical problem not listed:
Medications
List any medications you are currently taking:
Take a blood thinning medication Yes No
If yes, date of last protime:
Pharmacy Name:
Phone: - -
Allergies
Asprin
Barbiturates (sleeping pills)
Codeine
Local anesthetic
Penicillin
Sulfa
Latex
Other
If other, please describe:


I authorize treatment of the person named on this registration and agree to pay all fees and charges for such treatment as deemed necessary. I guarantee Dr. Trisha T. Goldsby payment of all charges for dental treatment and authorize payment to be made to her by my insurance co. The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of her staff responsible for any error or omissions that I may have made in the completion of this form.
   
  did you know?
 

• People who drink 3 or more sugary sodas daily have 62% more dental decay, fillings and tooth loss.

• The average person only brushes for 45 to 70 seconds a day, the recommended amount of time is 2-3 minutes.
- Academy of General Dentistry

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