PATIENT INFORMATION 2

Have you been hospitalized during the past 5 years?

Explain

Are you currently taking any medication?

List:

Are you pregnant?

How many weeks?

Do you smoke?

How much?

When was the last dental treatment/cleaning?

Where?

When was the last full mouth x-ray/panoramic taken?

Where?

Choose Yes or No for each question.

Does your jaw click when your open or close your mouth?

Do you habitually clench/grind your teeth during the night or the day?

Do you have head/facial muscle aches when you awake in the morning?

Have you ever been told you have gum decease?

Do your gums bleed when brushing or flossing?

Are you happy with your teeth/smile?

Are you interested in having teeth whitened?

Please let us know at least 24 hours in advance if you are unable to keep your appointment. This allows us time to accommodate the needs of other patients. Without this notice, you may be charged a $25.00 administrative fee. This fee will be due and payable before any additional appointments will be scheduled

I hereby give permission to the dentist(s) in charge to administer and perform treatment deemed necessary and advisable. I understand and agree that I am responsible for payment. I will be paying by:

Authorization must be signed by the patient or by the patients' legal guardian when the patient is a minor.

I certify that the above completed information is true and correct to the best of my knowledge and I will notify Ashley Dental Associates of any changes. I understand and agree that I am responsible for the balance of my account for professional services rendered, as well as any legal fees, attorney fees or collection fees incurred on my delinquent account(s).

Signature of Patient/ Parent or Legal Guardian
(please use your mouse to add your signature in the box below)

Date

I acknowledge the Notice of Privacy Policies and Practices for Ashley Dental Associates.

Signature of Patient/ Parent or Legal Guardian
(please use your mouse to add your signature in the box below)

Date

Treatment Plan

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