Steven Spivack, DDS

8815 Dyer Street, Suite 210 El Paso, TX 79904

915-745-7616

Thank you for choosing our practice for your dental needs. We strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please complete this form. If you have any questions or need assistance, we will be happy to help.

Patient Information
Today’s Date:
Name: Last
First
Preferred Name
Address:
City
State:
Zip
Birthdate:
SSN #
Sex
Home Phone
Cell Phone
Work Phone
Email
Facebook
Instagram
I prefer to be contacted via:
Select Appropriate Box
Employer
Occupation
If Student, Name of School:
City:
State:
Person to Contact in Case of Emergency:
Phone
Whom May We Thank for Referring You to Us?
Insurance Information
Name of Insured: Last
First
Relationship to Patient
Birthdate
SSN #
Driver’s License #
Employer
Work Phone
Employer Address:
Union or Local #
Insurance Company:
Group #
Policy/ID #
DO YOU HAVE ADDITIONAL INSURANCE?

IF YES, COMPLETE THE FOLLOWING:

Name of Insured: Last
First
Relationship to Patient
Birthdate
SSN #
Driver’s License #
Employer
Work Phone
Employer Address:
Union or Local #
Insurance Company:
Group #
Policy/ID #

Responsible Party

Name of person responsible for this account:
Relationship to Patient:
Address:
Phone
Is this Person Currently a Patient in our Office?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Patient's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Parent's Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Patient’s Dental History

Why have you come to see us today? (e.g.: pain, checkup, etc.)
Name of Previous Dentist and Location:
Date of Last Exam:
Are you nervous about seeing a dentist?
If yes, please tell us why:
Do you like your smile?
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to hot or cold liquids/foods?
Are your teeth sensitive to sweet or sour liquids/foods?
Do you feel pain to any of your teeth?
Do you have any sores or lumps in or near your mouth?
Have you had any head, neck or jaw injuries?
Have you ever experienced any of the following problems in your jaw?
Clicking
Pain (joint, ear, side of face)
Difficulty in opening or closing
Difficulty chewing
Do you have frequent headaches?
Are your teeth sensitive to hot or cold liquids/foods?
Do you bite your lips or cheeks frequently?
Have you ever had any difficult extractions in the past?
Have you ever had any prolonged bleeding following extractions?
Have you had any orthodontic treatment?
Do you wear dentures or partials?
If yes, date of placement
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Patient’s Medical History

I consider my health to be (Please check one):
Are you under medical treatment now?
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
If yes, please explain
Do you use tobacco?
Do you use controlled substances?
Do you wear contact lenses?

Doctor Notes Only

Initial Blood Pressure:
ASA:
Med Hx/Meds:
Allergies

Medical health reviewed by Doctor.

Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Do you have or have you had any of the following?

High Blood Pressure
Heart Attack
Rheumatic Fever
Swollen Ankles
Fainting / Seizures
Asthma
Low Blood Pressure
Epilepsy / Convulsions
Leukemia
Diabetes
Kidney Disease
AIDS or HIV Infection
Thyroid Problem
Heart Disease
Cardiac Pacemaker
Heart Murmur
Angina
Frequently Tired
Anemia
Emphysema
Cancer
Arthritis
Joint Replacement / Implant
Hepatitis / Jaundice
Sexually Transmitted Disease
Stomach Troubles / Ulcers
Chest Pains
Easily Winded
Stroke
Hay Fever
Tuberculosis
Radiation Therapy
Glaucoma
Recent Weight Loss
Liver Disease
Heart Trouble
Respiratory Problem
Mitral Valve Prolapse
Other

Are you allergic to or have you had any reactions to the following?

Local Anesthetics (e.g.: Novocaine)
Penicillin or any other Antibiotics
Sulfa Drugs
Barbiturates
Sedatives
Iodine
Aspirin/ Ibuprofen
Any Metals
Latex Rubber
Other

Women Only:

Are you pregnant or think you may be pregnant?
Are you nursing?
Are you taking oral contraceptives?

Please list all medications you are currently taking:

Signature:

Use your mouse cursor or the tip of your finger to sign below

Date: