Michael O Vernon D.M.D. Christopher M Moldovan D.M.D Augusta Dental Associates 1218 Augusta West Parkway Augusta, GA 30909 Welcome to our office. We will do our best to make your appointment as convenient and pleasant as possible.
If at any time you have any questions regarding your treatment, appointments, or fees, please feel free to ask.
Today’s Date: ___________________ Patients Date of Birth: _______________________
Person responsible for payment of service rendered (guardian) ______________________________________________________
Residence Address: ________________________________________________________________________________________
Email Address: ____________________________________________________________________________________________
Telephone: Home _______________Work _______________Cell ______________Social Security No: _____________________
Name of Business: ____________________________________________________Position:______________________________
Business Address: _________________________________________________________________________________________
Insurance (PLEASE READ THOROUGHLY)
As a courtesy to you, we can take assignment of your dental insurance benefits. To accurately file your claims, please present your dental insurance card and complete the following information. INFORMATION ABOUT THE PERSON WHO CARRIES THE DENTAL INSURANCE: Name: ______________________________
Social Security No.: ___________________________________ Date of Birth: __________________________________________
Dental Insurance Carrier: _____________________________________________________________________________________
Employer: _________________________________________________________Group Policy or Union No: __________________
Address to mail completed insurance claim: _______________________________________________________________________
Your total balance charged and dental insurance is your financial responsibility, but we can help. If you wish for us to file your dental insurance, we must ask that you be prepared after each visit to pay the ESTIMATED amount that the insurance will not cover based on the information provided by your insurance company.
I hereby authorize the release to and the use by
I hereby authorize the payment of dental benefits directly to
Michael O. Vernon, D.M.D., P.C. any dental or other information needed
in processing the claims resulting from treatment rendered in this office.
PLEASE SEE OTHER SIDE MICHAEL O. VERNON, D.M.D., P.C. CHRISTOPHER MOLDOVAN, D.M.D. 1218 Augusta West Parkway AUGUSTA, GA 30909
I understand that all fees incurred by my dependents or myself regardless of insurance coverage, is my responsibility and I will be liable for payment of these charges. ________________________________
(1) How would you classify your General Health (circle one)?
Excellent Good Fair Poor
(2) Are you presently under the care of a physician? If yes, for what? ______________________________________________________
(3) Personal Physician __________________________Address/Phone ______________________________________________________
Accurate and complete disclosure of medical information is necessary for proper diagnosis and to help prevent unnecessary complications during your treatment. PLEASE CHECK THE APPROPRIATE BOX for any conditions that you have now or had in the past. (Parent/Guardian: Please check the appropriate boxes concerning your child’s health status)
Cardiovascular (Heart) Nerves & Sensory Endocrine (Hormonal) Hematologic (Blood) Respiratory (Breathing) Dermal/Musculoskeletal Other Conditions Gastrointestinal (Stomach)
treatment for any health related conditions
(such as Artificial Valves, Artificial Joints,
Yes □ No □ When?Type? ___________________
Have you ever taken medication for Osteoporosis/Bone Disease to increase bone density (i.e. Fosamax, Boniva, Actonel, Aredia, Zometa, Reclast) Yes □ No □ Are you taking (or supposed to be taking) any medicine, drugs or pills of any kind (including Aspirin / non-prescription drugs)? Yes □ No □ If so, what? Are you allergic to any drugs or medicines (Including anesthetic)? Yes □ No □ If so, what drug?/What type of reaction did you have?
Please list any other medical conditions or concerns not mentioned above that the Doctor should be aware of:
WOMEN: Are you pregnant? Yes □ No □ How long (circle one)? 1-3 months 3-6 months 6-9 months
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, abnormal laboratory test, or medicine change, I will inform the dentist at the next appointment.
Please See Other Side → DENTAL HISTORY
(1) What prompted you to seek dental care at this time? ____________________________________________________________
(2) On a scale of 1 to 10 (10 being the highest), what priority do you give your teeth?
(3) Have you experienced any discomfort from your teeth or gums lately? . Yes No (4) Have you noticed any popping, clicking or tiredness of your jaw joint? . Yes No (5) Do you have any missing teeth that have not been replaced? . Yes No (6) Do you feel that you cannot chew well? . Yes No (7) When did you last have x-rays taken of your teeth? ______________________ Last cleaning? _________________________ (8) Do you receive any type of fluoride? . Yes No (9) The name and address/phone number (if available) of your former dentist: _________________________________________
(10) Why did you choose our office for your dental needs? __________________________________________________________
(11) Whom may we thank for referring you to our office? ___________________________________________________________
PREVENTIVE DENTAL HISTORY
(1) Have you been taught proper brushing methods? . Yes No (2) Have you been taught proper flossing methods? . Yes No (3) Do your gums bleed easily, especially when you clean them? . Yes No (4) Do you have any problems with bad breath? . Yes No (5) Have you ever been told you have gum disease (Pyorrhea)?. Yes No
(6) Is there anything you feel we should know to help us in your treatment? ____________________________________________
Augusta Dental Associates Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement**
This is to certify that I have received a copy of this office’s Notice of Privacy Practices
________________________________ __________________________________ ____________
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
( ) Communications barriers prohibited obtaining the acknowledgement ( ) An emergency situation prevented us from obtaining acknowledgement ( ) Other (Please Specify) ________________________________________________________________
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