DENTAL HISTORY

    SKYLINE FAMILY DENTISTRY

    Gabriel Overholtzer D.D.S.

    Patient info: MrMrsMiss Patient Name:
    Social Security Number : Date of Birth:
    Status:  ChildSingleMarriedOther Address:
    State: , Zip Code: Home #: 
    Work: Cell #:
    Emergency Contact: Relationship: , Phone#:
    Patient Employer or School : Occupation:
    Drivers License: Email:
    How did you hear about us? Refereed By: Source: NewspaperRadioDrove byOther
    Dental  History
    Have you been having any specific problem? YesNo Describe :
    Date of last Dentist Visit: Purpose:
    Last Date of Visit: Date of Last Exams:
    Has Fear of discomfort kept you from regular visit: YesNo How is your dental health? YesNo
    Do you feel you have decay? YesNo Gum Disease: YesNo
    Are your gums sensitive & bleed easily?  YesNo From your past leaning visits, what would you say your personal preference is? GentleMediumThorough
    How many times a day do you brush? How often do you floss?
    Do you use a waterPik? YesNo How do you feel about your smile? GoodFairPoor
    What would you like to change about it? YesNo  
    PRIMARY ISURANCE INFORMATION / RESPONSIBLE PARTY
    Relation to patient SelfSpouseParentsOther Name of Policy Holder:
    Social Security #: Date of Birth:
    Address: State: , Zip Code:
    House: Work:
    Cell: Emergency Contact:
    Relationship:  Phone:
    Patient Employer or School: [ text-PatientEmployerorSchool] Occupation:
    Insurance Company: Group:
    ID#: Insurance Phone:
    Insurance Address:

     

    Payment Policies

    BALANCES ARE DUE AT THE TIME OF SERVICE. IF YOU ARE INSURED YOU ARE RESPONSIBLE FOR ANY REMAINING BALANCE. ONCE YOUR INSURANCE HAS PAID. FEES ARE DETERMEINED BY THE SERVICES REQUIRED.

    CONSENTFOR SERVICES: I AUTHORIZE THE DR TO PERFORM THE NECESSARY TREATMENT AS NEEDED. I AUTHORIZE THE RELEASE OF ANY INFORMATION RELATING TO DENTAL TREATMENT TO THIRD PARTY PAYERS AND/ OR OTHER HEALTH PRACTIONERS FR MYSELF OR MY DEPARTMENTS. I HAVE READ THE ABOVE & AGREE TO THEIR CONTENTS.

     

    Agree: YesNo

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    Office Hours

    Monday: 8am – 5pm
    Tuesday: 8am – 5pm
    Wednesday: 8am – 5pm
    Thursday: 8 am – 5pm
    Friday: Closed
    Saturday: Closed
    Sunday: Closed

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