Online Medical History Form - Merlo and Fahrney Dentistry

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Online Medical History Formideaforge2020-05-11T14:43:29+00:00

Medical History

Step 1 of 4

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Name*
First Last
Preferred Name (Nickname)
First Last
Gender*
- Male
- Female
Marital Status*
Birth Date*
MM slash DD slash YYYY
Occupation*
Email*
Cell Phone*
Home Phone same as Cell Phone?*
- Yes
- No
Home Phone*
Address*
Street Address Address Line 2 City State ZIP Code
How did you find us?*

Primary Insurance
Insurance*
- I will not be using / or have any dental insurance.
- I will be using my dental insurance.
- I will also be using my secondary dental insurance.
Insured's ID*
Insurance Company Name*
Insurance Company Address
Street Address Address Line 2 City State ZIP Code
Insurance Company Phone #*
Name of Insured's Employer*
Relationship to patient*
Insured's Date of Birth*
MM slash DD slash YYYY
Group #*
Secondary Insurance
Insured Name*
First Last
Insured's ID*
Insurance Company Address
Street Address Address Line 2 City State ZIP Code
Insurance company name*
Insurance Company Phone #*
Name of Insured's Employer*
Relationship to patient*
Insured's Date of Birth*
MM slash DD slash YYYY
Group #*
Dental Insurance Release
DENTAL INSURANCE RELEASE - I authorize payment directly to the above named dentist of the insurance benefits otherwise payable to me for their services. I authorize the release of information relating to this claim including x-rays and study models.*
- Yes
- No
Financial Agreement
FINANCIAL AGREEMENT - I authorize treatment by the above named dentist. I accept financial responsibility for all treatment. I am aware that payment in full is expected at time of treatment unless prior financial arrangements have been made. I understand that even if insurance is filed, I am responsible for any balance not paid by insurance.*
- Yes
- No

Dental History
Why have you come to us today?*
When was your last dental cleaning?*
Have you had gum treatment or a deep cleaning before?*
- Yes
- No
If yes, please explain
Do you currently have any dental pain?*
- Yes
- No
If yes, please explain
Are your teeth sensitive to hot, cold, or anything else?*
- Yes
- No
If yes, please explain
Have you ever had any difficult / serious problem associated with previous dental work?*
- Yes
- No
If yes, please explain
Have you ever been required to premedicate with antibiotics before dental appointments?*
- Yes
- No
If yes, please explain

Medical History
Please take a moment to let us know about your medical and dental history so that we may serve you more effectively for your overall health and well-being.
Have you had any changes in your health, hospitalizations, or surgeries in the last 5 years?*
- Yes
- No
If yes, please explain
Are you undergoing any care due to a specific condition?*
- Yes
- No
If yes, please explain
Do you use any tobacco products?*
- Yes
- No
Do you have any total joint replacements?*
- Yes
- No
If yes, please explain
Please mark if you have experienced any of the following*
- Acid Reflux
- Anxiety/Nervousness
- Asthma
- Autoimmune disease
- Allergies/Hay fever
- ADD/ADHD
- Arthritis/Gout
- Autism
- Anemia
- Bleed Easily
- Blood Transfusion
- Birth Control pills
- Bisphosphonate Use
- Breathing Problems
- Cancer
- Cataracts
- Chemotherapy
- Colitis/Crohn's/IBS
- Coumadin/Aspirin
- Diabetes
- Depression
- Epilepsy/Seizures
- Fainting/Dizziness
- Fibromyalgia
- Glaucoma
- Headaches/Migraines
- Hearing Impaired
- Heart Attack/Surgery
- Heart Murmur/MVP
- Heart Problems-Other
- Hepatitis
- Herpes/Fever Blisters
- High Blood Pressure
- Hospitalization (any)
- HIV / AIDS
- High Cholesterol
- Alc/Drug Abuse (w/in 6m)
- Kidney Problems/Dis.
- Liver Problems/Disease
- Low Blood Pressure
- Low Blood Sugar
- Lupus
- Multiple Sclerosis
- Neck Pain/Head Injury
- Nerve Pain
- Pacemaker
- Radiation Treatment
- Rheumatic fever
- Sickle Cell Dis/Trait
- Sinus Problems
- Stroke/TIA
- Sleep Apnea
- Thyroid Problems
- Tuberculosis (TB)
- TMJ Problems
- Tumors
- Ulcers
- NONE
Allergies*
- Latex
- Penicillin
- Codeine
- Aspirin
- NONE
Other
Are you currently taking any over the counter or prescription medications?*
- Yes
- No
If yes, please list all
Nursing?
- Yes
- No
If yes, how many weeks pregnant
Privacy Policy*
- I have read and understand the Privacy Policy.
Signature
Appointments
We will always respect your time, and our team will make every effort to schedule appointments that accommodate the needs of all of our patients. In return, we ask that our patients make every effort to keep their reserved dental appointments.
As a courtesy you will receive verification of your appointment via text and email beginning 2 weeks prior to your appointment. We understand emergencies may arise and personal schedules may have unforeseen changes that prevent patients to keep their planned appointments. In the event you should need to reschedule an appointment, we ask for the consideration of a 48 hour notice. If an appointment is broken or an appointment is missed, it creates scheduling challenges for other patients as well as for our office.
** Repeated cancellations without adequate advanced notice will be subject to a non-refundable $50.00 broken appointment fee. For any further missed or broken appointments, our office reserves the right to dismiss a patient from the practice

Payments Options
For your convenience we accept payment in forms of cash, check, all major credit cards as well as no interest financing through CareCredit.
**CareCredit may be applied for prior to your appointment online at www.carecredit.com.
Any checks returned unpaid by your bank will be charged a $30.00 returned check fee and future payments will only be accepted in forms of cash or credit.

Copays and Estimates
We make every effort to provide the most accurate estimates for cost of treatment based on the information provided by your insurance company. All applicable payment for services will be collected at the time of your visit. While we will estimate your dental benefits to the best of our ability, this is an estimate ONLY, and should not be depended on as the final decision. Should questions arise, it is best to contact your insurance company directly. We encourage any patient utilizing dental coverage to understand the limitations within your dental policy.

Important Dental Insurance Information
We are pleased to inform our patients we accept insurance benefits from most dental carriers. As a courtesy to you we will file dental claims on your behalf and allow 30 days for your insurance policy to reimburse our office for treatment. Unpaid claims after 30days for any reason will default to the patient’s responsibility. Any procedures not covered by insurance will require full payment at time of service. Please be mindful you are fully responsible for all fees associated with treatment provided regardless of your insurance decision to provide coverage. In the event insurance has paid less than we had anticipated you will be sent a statement for any remaining balance. Payment is due upon receipt. *Payments over 30 days will incur a 20% finance charge to the unpaid balance each month it is carried **Accounts turned over to collections will incur a fee equal to 35% of the outstanding balance.

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