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Have you ever had any of the following? Please check those that apply:
Allergies (list below)
High Blood Pressure
Pins/plates in bone
Have you ever had any complications following dental treatment?
Have you been admitted to a hospital or needed emergency care during the past two years?
Are you now under the care of a physician?
Do you have any health problems that need further explanation?
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.
Whom may we thank for referring you to SmileLogic, Inc.?
Responsible Party Information (if not yourself)
(We want to get to know you!)
Reason for today’s visit
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?
Do you have 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.