Dr.Tom Lee, DDS Patient Information Form- Fax Version Only
To use this form, just print out, complete and fax.
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Patient Information Insurance Information
Patient Name . Insured's Name .
Patient Address
 .   Address .
Patient HomePhone . City,St,Zip .
Patient Bus Phone . Employer .
Patient Birthdate . Employer Address .
Patient Sex

Male     Female     

Insurance Co .
Patient Employer . Ins Co Address .
Patient Occupation . Group No .
Patient SS No . Policy No .
Insurance Coverage? Yes         No    Local No .
Patient Referred by . Birthdate .
Person Responsible for Account SSN .
Name E-mail .
  Address . Phone .
City,St,Zip .

Second Insured's Information
HomePhone . Name .
WorkPhone . Address .
Birthdate . City,St,Zip .
Relationship to Patient . Employer .
Employer . Work Address .
Position . Insurance Co .
SSN . Ins Co Address .
Group No .
Policy No .
Local No .

BirthDate

.

In Case of Emergency

 SSN .
Name . E-Mail .
Phone . Phone .
Relationship to Patient . HomePhone .

MEDICAL AND DENTAL INFORMATION
Do you have, or have you had any of the following:
1___________Asthma 11__________Tuberculosis 21__________Prosthetic joint
2___________Allergy 12__________Anemia 22__________High blood pressure
3___________Diabetes 13__________Sinus Trouble 23__________Prolonged bleeding
4___________Hepatitis 14__________Kidney Trouble 24__________Epilepsy
5___________Jaundice 15__________Heart Trouble 25__________Fainting Spells
6___________Arthritis 16__________Heart Murmur 26__________Persistent cough
7___________Stroke 17__________Rheumatic fever 27__________Tumor benign or malignant
8___________Alcoholism 18__________Herpes 28__________Glaucoma
9___________AIDS 19__________Venereal Disease 29__________Blood transfusions
10__________Heart Arrhythmias 20__________Mitral Valve Prolapse 30__________Surgery
Explanation of Medical Answers (refer to the number of the item checked above)

 
Reason for today's Visit

 
How Long Since Last Medical Exam? How Long Since last Dental Cleaning/Exam?
Have You Experienced Unfavorable Dental Treatment?

 
List any medications you are taking:

 
Have you experienced any allergic or unusual reaction to:   ______ Penicillin     ______ Aspirin       ______Codeine              
        _______Dental Anesthetic      _______ Any Other Drug_______________________________________
Physician Name Physician Phone
Do you or have you had any illness or problems not listed above that we should know about? ______Yes______No
Please List.:

 
Women:  Are You Pregnant?       _____Yes_____No If Yes, Which trimester?

Permit for treatment care and surgical care: I hereby grant permission for the staff of Dr.Tom Lee,DDS to employ such established treatments and therapy as may be deemed professionally necessary or advisable.  For most dental procedures, local anesthetic is administered.  Risks involved may include the following:  heart palpitation, allergic reaction, hematoma, parathesia, and/or drug cross reaction.   FINANCIAL AGREEMENT:  all charges for services and treatment will be paid upon completion of appointment.  All outstanding balances over 90 days shall accrue interest at the rate of 1% per month.  IF INSURANCE IS INVOLVED: I hereby authorize payment to Dr.Tom Lee,DDS, otherwise payable to me 
I certify that the above information is true and correct.

____________________________________                         _____________________
Patient or guardian or guarantor's signature                                 Date Signed

Final step: Fax this completed, signed form to Dr Lee's office (425) 226-2188.  
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