Patient Information | Broomfield, CO

Patient Name

Last Name *

First Name *

Middle Name

Preferred Name *

Appointment Date *

Gender

MaleFemale

Date Of Birth *

Age

Email *

Phone *

Other Phone

Address *

City *

State *

Zipcode *

Health Information

Last Visit Date

MD Name *

MD Phone *

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 *

Tobacco Use *

Have you ever had any complications following dental treatment? *
If yes, please explain

Have you been admitted to a hospital or needed emergency care during the past two years? *
If yes, please explain

Are you now under the care of a physician? *
If yes, please explain

Do you have any health problems that need further explanation? *
If yes, please explain

Name of Emergency Contact *

Phone of Emergency Contact *

Medications *

Allergies (including prescription drugs) *

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)

Referral Date of Birth *

Referral Phone *

Referral Work Phone *
Ext.

Best time to call *

Address*

City *

State *

Zipcode *

Employer Name *
Employer Phone *

Employer Address *

About You

(We want to get to know you!)

Occupation (or school if student) *

Hobbies/interests *

Something unique about you *

Dental History

Name of Dentist (current or former) *

Date of last visit mm/dd/yy *

Reason for today’s visit *

Current homecare *

Please select

BrushFlossWaterPikother

Do you like your smile? *

Have you ever used or interested in any whitening products? *

Do your gums bleed while brushing or flossing? *

Do you feel pain in your mouth or teeth? *

Any lumps or sores in or near your mouth? *

Do you have jaw pain? *

Are your teeth sensitive to hot/cold? *

Are your teeth sensitive to sweet? *

Do you grind or clench your teeth? *

Do you wear a night guard or retainer? *

Do you have frequent headaches? *

Do you have any dental implants? *

Do you have dentures or partial dentures? *

Are you worried that you have bad breath? *

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.

Relationship to Patient

How did you hear about us?*