Abbott Family Dentistry LLC	   PATIENT NAME: 				                                       PT#			
	           PATIENT HEALTH HISTORY:  	PLEASE CHECK Y FOR YES AND N FOR NO TO ALL BELOW 
		Y  N					Y  N					Y  N
		O  O   HEART MURMUR		O  O   SICKLE CELL ANEMIA 		O  O   SINUS TROUBLE
		O  O   HEART FAILURE		O  O   DRUG ALLERGIES List below	O  O   TUBERCULOSIS (TB)
		O  O   ANGINA PECTORIS		O  O   PENICILLIN ALLERGY		O  O   TUMOR, GROWTH or CANCER
		O  O   HEART DISEASE or ATTACK	O  O   LATEX ALLERGY		O  O   CHEMO / RADIATION THERAPY
		O  O   STROKE				O  O   ALLERGIC TO ANESTHETICS	O  O   HIV / AIDS
		O  O   HEART SURGERY within 6mos	O  O   ALLERGIC TO SULFITES	O  O   HEMOPHILIA					O		O  O   RHEUMATIC FEVER 		O  O   METHACRYLATE ALLERGY	O  O   ANEMIA
		O  O   HIGH BLOOD PRESSURE	O  O   OTHER ALLERGIES list below	O  O   DIABETIC
		O  O   ASTHMA			O  O   ARTHRITIS			O  O   GLAUCOMA
		O  O   PHEN PHEN USE HISTORY	O  O   HEPATITIS &/or CARRIER	O  O   TOBACCO USE
		O  O   JOINT SURGERY within 2yrs	O  O   THYROID PROBLEMS		O  O   DAILY ASPIRIN USER
		O  O  OTHER SURGERY within 2yrs	O  O   KIDNEY PROBLEMS		O  O   PREGNANT
		O  O  ARTIFICIAL JOINT		O  O   LIVER PROBLEMS		O  O   EPILEPSY &/or SEIZURES	
	    	O  O  OSTEOPOROSIS 		O  O   TEETH WHITENING Last 2wks	O  O   DEMENTIA / ALZHEIMERS
		O  O  MIGRAINES / HEADACHES	O  O   TMJ / JAW MUSCLE PAIN	O  O   SLEEP APNEA / SNORING
              ARE YOU TAKING ANY DRUGS FOR OSTEOPOROSIS OR BONE DENSITY? _______________________________________________________
 	   ARE YOU TAKING FOSAMAX OR ANY BISPHOSPHONATE DRUGS? _______________________________________________________________
              LIST OTHER DRUGS YOU ARE ALLERGIC TO :													    LIST	OTHER HEALTH PROBLEMS : 												
	    WHAT PRESCRIPTION DRUGS ARE YOU TAKING (Including Birth Control) ? 							
	    																
	    WHAT NON-PRESCRIPTION DRUGS ARE YOU TAKING ? 									
	    DO YOU USE RECREATIONAL OR STREET DRUGS ? 		 if yes, please list 					
	    DO YOU HAVE ANY DENTAL CONCERNS YOU WOULD LIKE TO DISCUSS WITH THE DOCTOR ? 							    DO YOU GIVE PERMISSION TO DISCUSS DENTAL TREATMENT WITH YOUR SPOUSE and/or PARENT ?																							NT FOR 
  TREATMENT : I GIVE CONSENT FOR TREATMENT FOR MYSELF, OR THE PATIENT LISTED.  IF AN EMERGENCY, I GIVE CONSENT FOR 				   NECESSARY TREATMENT FOR TREATING THE EMERGENCY.  I  AGREE TO FOLLOW TREATMENT PLANS PROVIDED BY THE DOCTOR,		``		   INCLUDING ANY AND ALL POST CARE INSTRUCTIONS.  I UNDERSTAND THAT ANY TREATMENT MAY CAUSE POST DISCOMFORT AND  			   THAT THERE IS NO GUARANTEE OR WARRANTY FOR ANY SUCH TREATMENT.  I WILL DISCLOSE MY COMPLETE HEALTH HISTORY				    PRIOR TO TREATMENT AND WILL PROVIDE ANY CHANGES.  

            INSURANCE : AS A NEW PATIENT, PAYMENT IS DUE AT TIME OF SERVICE UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE  AFTER			   MY INITIAL VISIT.  AS A COURTESY, Abbott Family Dentistry LLC WILL BILL MY PRIMARY INSURANCE.  I WILL BE EXPECTED TO REMIT ANY			   DEDUCTIBLE &/or CO-PAY, IF APPLICABLE, AT TIME OF EACH VISIT.  WHEN TIME PERMITS, Abbott Family Dentistry LLC MAY  CONTACT MY 			   INSURANCE  TO VERIFY ELIGIBILITY AND ALSO ACQUIRE AN ESTIMATE OF  DENTAL BENEFITS.  ANY INFORMATION PROVIDED BY MY 	   
	   INSURANCE IS ONLY AN ESTIMATE AND NOT A GUARANTEE OF BENEFITS OR A GUARANTEE OF PAYMENT.  I UNDERSTAND THAT IT IS 			   MY RESPONSIBILITY TO UNDERSTAND THE SPECIFICS OF  MY INSURANCE PLAN.  I AM AWARE THAT MY INSURANCE PLAN MAY PAY 			   AN ALTERNATE BENEFIT FOR ANY PROCEDURE AND I AM RESPONSIBLE FOR THE DIFFERENCE IN FEES.  Abbott Family Dentistry LLC WILL 			   NOT BE RESPONSIBLE FOR CONTACTING MY INSURANCE AT EACH VISIT TO VERIFY BENEFITS &/or ELIGIBILITY.  IT IS ENTIRELY MY 		 	  	   RESPONSIBILITY TO BE AWARE OF ANY CHANGES TO MY DENTAL BENEFITS &/or ELIGIBILITY FOR SAID BENEFITS. Abbott Family Dentistry
	   LLC WILL NOT BE RESPONSIBLE FOR TRACKING THE AMOUNT OF INSURANCE BENEFITS REMAINING FOR ANY INSURANCE COVERAGE	                                                         	   INCLUDING SECONDARY INSURANCE.  IT IS MY RESPONSIBILITY TO BE AWARE IF I HAVE EXHAUSTED MY SAID INSURANCE BENEFITS.	  		
	      PAYMENT : I UNDERSTAND THAT PAYMENT IS DUE AT TIME OF SERVICE.  AFTER A CLAIM IS SUBMITTED ON MY BEHALF, MY BALANCE 			    IS  DUE WITHIN 45 DAYS OF TREATMENT WHETHER INSURANCE HAS MADE A PAYMENT OR NOT.  THERE WILL BE A MINIMUM FEE OF			    $30.00 FOR ALL NON-SUFFICIENT ITEMS.  AFTER 60 DAYS, PAST DUE ACCOUNTS WILL BEGIN TO ACCRUE INTEREST AT  A  MONTHLY 		     	    RATE OF 0.8%, 10.5% APR.  Abbott Family Dentistry LLC RESERVES THE RIGHT TO REPORT PAST DUE ACCOUNTS TO THE CREDIT BUREAU
           AND  TO TRANSFER ACCOUNTS TO COLLECTIONS.  IF SENT TO COLLECTIONS, INTEREST IS CALCULATED FROM DATE OF SERVICE.

    APPOINTMENTS : IN THE EVENT THAT I AM UNABLE TO KEEP A SCHEDULED APPOINTMENT, I WILL  INFORM Abbott Family Dentistry LLC 	 		     AT LEAST TWO BUSINESS DAYS PRIOR TO  MY SCHEDLUED APPOINTMENT.  I UNDERSTAND THAT Abbott Family Dentistry LLC  
    RESERVES  THE RIGHT TO CHARGE A FEE FOR A BROKEN OR MISSED APPOINTMENT IN THE AMOUNT OF $120.00 PER HOUR or 
     THE ESTIMATED FEE FOR MY VISIT, WHICHEVER IS LESS. 		
  SIGNATURE							        DATE