WELCOME TO SMILE MAGIC DENTISTRY (PAGE 1 OF 2 PAGES)
PATIENT INFORMATION DENTAL INSURANCE
Date_________________ ID#/SS#_______________ Who is responsible for this account?_____________
Name__________________________________________ Relationship to Patient________________________
Address________________________________________ Insurance Co________________________________
City____________________State____Zip____________ Group#_____________________________________
Sex: Male  Female Age____Birthdate________ Is patient covered by additional insurance? Yes  No
Single Married Widowed Separated Divorced Subscriber's Name____________________________
Occupation_____________________________________ Birthdate________________SS#________________
Employer _____________________________________ Relationship to Patient________________________
Employer Address_________________________________ Insurance Co________________________________
Employer Phone___________________________________ Group#_____________________________________
Spouses Name____________________________________ ASSIGNMENT AND RELEASE
Birthdate____________________SS#_________________ I, the undersigned certify that I (or my dependent) have insurance coverage with __________________ and assign directly to Dr. Nazir all insurance benefits. If any otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance admissions.
Occupation______________________________________
Spouses Employer_________________________________
Birthdate___________________SS#_________________
Occupation_____________________________________
Spouse's Employer________________________________ ___________________________________________
Whom may we thank for referring you?_______________ Responsible Party Signature
_______________________________________________ ____________________________________________
Relationship                                         Date
PHONE NUMBERS
Home (____)______________ Work(____)________________Ext_____ Spouse's Work(____)________________
Best time to reach you___________________ EMERGENCY CONTACT (specify someone who does not live in your household):
Name_______________________________________ Relationship_____________________________________
Home Phone (____)_____________________ Work Phone (____)__________________________Ext_________
DENTAL HISTORY
Reason for todays visit _________________________________________________________________________________
Former Dentist:___________________City/State____________________Date of Last Dental X-Ray_________________
Bleeding Gums yes  No Blisters on lips or mouth yes  No
Burning sensation on tongue yes  No Loose teeth or broken fillings yes  No
Chew on one side of mouth yes  No Mouth breathing yes  No
Cigarette, pipe, or cigar smoking yes  No Mouth pain, brushing yes  No
Clicking or popping jaw yes  No Orthodontic treatment yes  No
Dry mouth yes  No Pain around ear yes  No
Fingernail biting yes  No Periodontal treatment yes  No
Food collection between the teeth yes  No Sensitivity to cold yes  No
Foreign Objects yes  No Sensitivity to heat yes  No
Grinding teeth yes  No Sensitivity to sweets yes  No
Gums swollen or tender yes  No Sensitivity when biting yes  No
Jaw pain or tiredness yes  No Sores or growths in your mouth yes  No
Lip or cheek biting yes  No Bleeding Gums yes  No
How often do you floss? _________ How often do you brush? _________
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