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Home
About
Services
Testimonials
Patient Forms
Volunteer Work
Location
Blog
Contact
Patient Information
Patient Name
Gender
Male
Female
Health Information
Have you ever had any of the following? Please check those that apply:
AIDS
Allergies (list below)
Asthma
Anemia
Arthritis
Artificial Joints
Cancer
Blood Disease
Cold Sores
Diabetes
Dizziness
Epilepsy/seizures
Excessive Bleeding
Fainting
Glaucoma
Growths
Hay Fever
Head Injuries
Heart Disease
Heart
Murmur
Hepatitis
High Blood Pressure
Jaundice
Kidney Disease
Liver Disease
Mental Disorders
Nervous Disorders
Pacemaker
Pregnancy
Radiation Treatment
Respiratory Prob
lems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
Thyroid Problem
Joint Replacement
Pins/plates in bone
Have you ever had any complications following dental treatment?
yes
No
Have you been admitted to a hospital or needed emergency care during the past two years?
yes
No
Are you now under the care of a physician?
yes
No
Do you have any health problems that need further explanation?
yes
No
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will in form the hygienist at the next appointment without fail.
Referral Information
Whom may we thank for referring you to SmileLogic, Inc.?
Responsible Party Information (if not yourself)
Male
Female
Married
Single
Child
Other
About You
(We want to get to know you!)
Dental History
Reason for today’s visit
Current homecare
Brush
Floss
WaterPik
other
Do you like your smile?
Have you ever used or interested in any whitening products?
Do your gums bleed while brushing or flossing?
Yes
No
Do you feel pain in your mouth or teeth?
Yes
No
Do you have any lumps or sores in or near your mouth?
Yes
No
Do you have jaw pain?
Yes
No
Are your teeth sensitive to hot/cold?
Yes
No
Are your teeth sensitive to sweet?
Yes
No
Do you grind or clench your teeth?
Yes
No
Do you wear a night guard or retainer?
Yes
No
Do you have frequent headaches?
Yes
No
Do you have any dental implants?
Yes
No
Do you have dentures or partial dentures?
Yes
No
Are you worried that you have bad breath?
Yes
No
Consent for Services
I understand that I am being seen by a licensed Colorado Dental Hygienist. I understand that is recommended that I see a licensed Colorado Dentist for dental exams yearly and that I am responsible for obtaining those exams.
I understand that Smile Logic will have my radiographs viewed and evaluated by a licensed dentist.
I understand that communication will be done via email and that it may not be encrypted. (appointment reminders, x-rays, treatment notes, etc.) Things like social security number and account information will not be shared, unless with an insurance company, which is encrypted.
Payment is solely the responsibility of the patient or responsible party. We will gladly bill insurance as a service to you, but any nonpayment or partial payment is then the patients responsibility. Non payment may result in turning over your account to a collections agency.
I have read the above conditions of treatment and payment and I agree to their content.
