Cosmetic, Restorative & Implant Dentistry

Dr Lee's Fairwood Dentistry is the place to call for 
Metal-Free Natural Aesthetic Dentistry   Digital X-Rays-(90% less Radiation) 
and Nitrous Oxide for Nervous Patients

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Patient Information Form Online
To print out a form and fax to the office, Use the Fax Version

Patient Information
Patient Name

Patient Address

Patient HomePhone

Patient Bus Phone

Patient Birthdate

Patient Sex

Male   

Female     

Patient Employer

Patient Occupation

Patient SS No

Patient Insurance Coverage?

 Yes           

No
Patient Referred by

Person Responsible for Account

Responsible Party Name

Responsible Party  Address

Responsible Party City,St,Zip

Responsible Party HomePhone

Responsible Party WorkPhone

Responsible Party Birthdate

Responsible Party: Relationship to Patient

Responsible Party Employer

Responsible Party:Position

Responsible Party SSN

Responsible Party E-Mail 


In Case of Emergency

 

Emergency Notification Name

Emergency Notification Phone

Emergency Relationship to Patient


Insurance Information

 

Insured's Name

Insured's Address

Insured's City,St,Zip

Insured's Employer

Insured's Employer's Address

Insured's Insurance Co

Insured's Insurance Co Address

Insured's Insurance Group No

Insured's Insurance Policy No

Insured's Local No

Insured's Birthdate

Insured's SSN

Insured's E-mail

Insured's Phone


Second Insured's Information

 

Second Insured'sName

Second Insured's Address

Second Insured's City,St,Zip

Second Insured's Employer

Second Insured's Employer's Address

Second Insured's Insurance Co

Second Insured's Ins Co Address

Second Insured's Group No

Second Insured's Policy No

Second Insured's Local No

Second Insured's BirthDate

Second Insured's SSN

Second Insured's E-Mail

Second Insured's Phone

Medical and Dental Information
Do you have or have you had any of the following:

1.  Asthma 2.  Allergy 3.  Diabetes
4.  Hepatitis 5.  Jaundice 6.  Arthritis
7.  Stroke 8.  Alcoholism 9.  AIDS
10.Heart Arrhythmia 11.Tuberculosis 12.Anemia
13.Sinus Trouble 14.Kidney Trouble 15.Heart Trouble
16.Heart Murmur 17.Rheumatic fever 18.Herpes
19.Venereal Disease 20.Mitral Valve Prolapse 21.Prosthetic joint
22.High blood pressure 23.Prolonged bleeding 24.Epilepsy
25.Fainting Spells 26.Persistent cough 27.Tumor benign or malignant
28.Glaucoma 29.Blood transfusions 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:
PenicillinAspirinCodeineDental AnestheticOther Drugs
Physician NamePhysician Phone
Do you or have you had any illness or problems not listed above that we should know about?
   YESNO    If yes, indicate here
WOMEN: Are you pregnant? YESNOIf 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.

Final step: Click on the SUBMIT button. Submission of this form online is the same as signing and faxing or delivering this information by mail, or in person. All information held in strict confidence.

  

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