Dental Forms

[ABOUT YOU] 1 of 6

Welcome Form

ABOUT YOU
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Please type your full name.
Please type your Nickname
Please specify your gender
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Please type your Social Security #.
Please type your home address.
Please type your home phone no.
Please type your cell no.
Where & when are the best times to reach you?
Whom may we Thank for referring you?
Other family members seen by us:
Please type your full employer's address.
Neighbor or Relative not living with you
Please type your full address.
Person responsible for Account if other than yourself
Please type your full billing address.
SPOUSE INFORMATION
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INSURANCE INFORMATION
Primary Insurance
Please specify your position in the company
Please specify your position in the company
Please specify your position in the company
Please type your full insurance co. address.
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Please type your full employer's address.
Secondary Insurance
Please specify your position in the company
Please specify your position in the company
Please specify your position in the company
Please type your full insurance co. address.
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Please type your full employer's address.
DENTAL HISTORY
Are you currently in pain?
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Do you require antibiotics before dental treatment?
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Have you experienced problems associated with any previous dental work?
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Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?
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Your current dental health is:
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Type of bristles on your toothbrush?
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How long do you use a toothbrush before replacing it?
Do you use anything in addition to your brush and floss?
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Woud you like fresher breath?
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Have you ever had periodontal disease?
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Do you have mobility in your teeth?
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Are your teeth sensitive to heat, cold, or anything else?
Do you still have wisdom teeth?
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Please specify your position in the company
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Why did you leave your previous dentist?
What did you like most & least about any dentist you have seen?
Are you happy with the way your smile looks?
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If not, what would you change?
MEDICAL HISTORY
Do you have a personal physician?
Please specify your position in the company
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Your current physical health is:
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Are you currently under the care of physician?
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Do you smoke or use tobacco in any other form?
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Have you been told that you snore or hold your breath while sleeping or wake up gasping for breath?
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Have you ever taken Fosamax, or any other Bisphosphonate?
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Are you allergic to any of the following
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Please list additional drugs / marterials that cause of allergic reactions:
For Women: Are you taking birth control pills?
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Please specify your position in the company
Are you taking any of the following?
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Are you taking any prescription, over-the-counter drugs, herbal remedies, vitamins or minerals not listed above?
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Do you or have you experienced the following?
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Please list any serious medical condition(s) that you have experienced:
AUTHORIZATIONS
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental service I may need. My method of payment will be
Please enter your payment method
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Please select a date
PAYMENT IS DUE AT TIME OF SERVICE
Our officce is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I certify that I am covered by:
Please type insurance name
Insurance Co. and I assign directly to Dr.
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all insurance benefits, otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
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Please select a date
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David Suga DDS
1505 Dillingham Blvd. Suite 210
Honolulu, Hawaii 96817
Telephone # (808) 841-5633
Fax: (808) 845-5273

dsuga1@hawaii.rr.com or mercie@hawaii.rr.com

David Suga, DDS
Dentist


Mercie Uy
Practice Manager

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