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DR. WILLIAM R. PIKE

600 So. Saint Vrain Ave, Suite 3 Estes Park, CO 80517

970-586-9434

Dental History

Patient Name
Patient Account Number
E‐mail
Phone
Medical Alert

Welcome! So that we may provide you with the best possible care please complete both Mwdical/dental form. All information is completely confidential.

What is the reason for your visit today?
Date of Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-rays
What was done at your last dental visit?
Previous Dentist's Name
Telephone
Address
State
Zip
How often do you have dental examination?
How often do you brush your teeth?
How often do you floss?
Have you ever used or are you currently using floride?
What other dental aids do you use? (interplak, toothpick, etc.)
Do you have dental problems now?
If Yes, please describe:
Are any of your teeth sensitive to:
Hot or Cold?
Sweets?
Biting or Chewing?
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters or any other oral lesions?
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?
Does food tend to become caught in between your teeth?
If Yes, where?
Do you:
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth?(pencils,etc.)
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Snore or have any other sleeping disorders?
Smoke/chew tobacco or use other tobacco products?
Have you ever had:
Orthodontic treatment?
Oral Surgery?
Periodontal treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?
Please describe, including cause
Have you experienced:
Clicking or popping of the jaw?
Pain? (joint, ear, side of face)
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Headaches, neckaches or shoulder aches?
Sore muscles (neck, shoulders)?
Are you satisfied with your teeth's appearance?
Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment?
Please describe
Have you ever had an upsetting dental experience?
Please describe
Have you ever been told to take a pre-medication prior to dental treatment?
Is there anything else about having dental treatment that you would like us to know?
If Yes, please describe

Medical History

Physician's Name
Phone
Have you had any medical care within the past two years?
Describe
Have you taken any medication or drugs during the past two years?
If Yes, please list name and dosage
Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?
If Yes, please list name and dosage
Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other bisphosophonates?
If Yes, please list name and dosage
Are you aware of having an allergic (or adverse) reaction to any substance or medication?
If Yes, please specify
Have you been a patient in the hospital during the past five years?

Indicate which of the following you have had, or have at present. Check "yes" or "no" to each item.

Heart (Surgery, Disease, Attack)
Asthma
Chest Pain
Hay Fever/Allergy/Hives
Congenital heart Disease
Latex Sensitivity
Heart Murmur
Sinus Trouble
High/Low Blood Pressure
Radiation Therapy
Mitral Valve Prolapse
Chemotherapy
Artificial Heart Valve/Pacemaker
Tumors
Rheumatic Fever
Hepatitis A B C
Arthritis/Rheumatism
Venereal Disease
Cortisone Medicine
A.I.D.S/H.I.V. Positive
Swollen Ankles
Cold Sores/Fever Blisters
Stroke
Blood Transfusion
Diet (Specia/Restricted)
Hemophillia
Artificial Joints (hip,knee,etc.)
Sickle Cell Disease
Kidney Trouble
Bruise Easily
Ulcers
Liver Disease/Yellow Jaundice
Diabetes
Neurological Disorders
Thyroid Problems
Epilepsy or Seizures
Glaucoma
Fainting or Dizzy Spells
Contact lenses
Nervous/Anxious
Emphysema
Psychiatric/Psychological Care
Chronic Cough
Cancer
Tuberculosis
Have you lost or gained more than 10 pounds in the past year?
Do you or have you had any disease, condition or problem not listed?

Women

Are you pregnant or think you could be pregnant?
If Yes, Months
Nursing?
Do you use birth control prescriptions?

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. l will notify the doctor of any change in my health or medication.

Parent/Guardian Signature:

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Date:

Doctor's Signature:

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Name:
Date:

Patient Registration

PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION

If this appointment is for you start here

Date
Last Name
First Name
M.I.
Prefers to be called by
Address
City
State
Zip
Home Phone No.
Fax
Cell
Email
Birth Date
Age
Gender
Marital Status
Soc. Sec

If this appointment is for your child start here

Date
Last Name
First Name
M.I.
Address
City
State
Zip
Home Phone
Birth Date
Age
Gender
School
Grade
Soc. Sec

Primary Dental Carrier

Insurance Company
Provider Phone
Group No.
Employer Name
Insured's Name
Date Of Birth
Relationship to Patient
Insured's ID No.
Insured Soc. Sec:

Secondary Dental Carrier

Insurance Company
Provider Phone
Group No.
Employer Name
Insured's Name
Date Of Birth
Relationship to Patient
Insured's ID No.
Insured Soc. Sec:

NOTE: Please email a copy of your Insurance Card to drwilliamrpike@gmail.com

Getting to know you

IS ANOTHER MEMBER OF YOUR FAMILY OR RELATIVE A PATIENT AT OUR OFFICE?
Name
Relationship
YOU WERE REFERRED TO US BY
Name
PERSON TO CONTACT FOR EMERGENCY
Name
Cell Number
Home Number
Address
City
State
Zip

Account Information

PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT
Name
Relationship
Soc. Sec:
Address
Phone No.
City
State
Zip
YOU
Name
Occupation
Employer's Name
Address
City
Phone No.
Fax
YOUR SPOUSE
Name
Occupation
Employer's Name
Address
City
Phone No.
Fax

Consent For Treatment

  1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient) 's dental needs.
  2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
  3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
  4. I give consent to the doctor's or designated staff's use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the min i mum amount of information necessary to provide quality ca re will be used or d isclosed and that a notice fully outlining the protection of my personal health information is available.
  5. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.
  6. Cell Phone: I consent to the dental practice using my cell phone number to (choose one or both) call or text regarding appointments and to call regarding treatment, insurance, and my account. I understand that I can withdraw my consent at any time.
    My cell phone number is (include area code)

 

Patient's Signature:

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Date:
Witness:

Parents/Responsible Party's Signature:

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Relationship:

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