Gender MaleFemale

Health Information

Have you ever had any of the following? Please check those that apply:
Have you ever had any complications following dental treatment?
yesNo
Have you been admitted to a hospital or needed emergency care during the past two years?
yesNo
Are you now under the care of a physician?
yesNo
Do you have any health problems that need further explanation?
yesNo


Referral Information

Whom may we thank for referring you to SmileLogic, Inc.?

Responsible Party Information (if not yourself)



About You

(We want to get to know you!)


Dental History

Do your gums bleed while brushing or flossing? YesNo
Do you feel pain in your mouth or teeth? YesNo
Do you have any lumps or sores in or near your mouth? YesNo
Do you have jaw pain? YesNo
Are your teeth sensitive to hot/cold? YesNo
Are your teeth sensitive to sweet? YesNo
Do you grind or clench your teeth? YesNo
Do you wear a night guard or retainer? YesNo
Do you have frequent headaches? YesNo
Do you have any dental implants? YesNo
Do you have dentures or partial dentures? YesNo
Are you worried that you have bad breath? YesNo

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.