Michael Tenorio, DDS

1623 South Washington, Amarillo, TX 79102

806-372-9511

Health History

Patient Name:
Home Phone
Cell Phone
Gender
Mailing Address
City
State
Zip
Email
Birth Date
Driver's License No
Marital Status
Do you desire to change or enhance your smile?
If so,how?
Present Position (patient)
How long?
Employer
Bus. Phone & Ext.
Name of Spouse/ Parent
Employer
How long?
Person Responsible for Account
Relationship
Insurance Co.
Policy No.
Patient's Social Security No.
Spouse/Parent Social Security #
Referred by
Chief Dental Complaint

GENERAL HEALTH

In the following questions, select yes or no, whichever applies. Your answers are for our records only and will be considered confidential.

Has there been any change in your general health within the past year?
Your last physical examination was on
Are you under the care of a physician?
If so what is the condition treated?
The name of your physician is
Have you had any serious illness or operation?
If so what is the condition treated?
Have you been hospitalized or had a serious illness within the past five (5) years?
What was the problem?
Date of last dental exam?
Date of last dental X -rays?
How often do you brush?
How often do you floss?

Please check any of the following conditions that apply to you:

Does your medical history indude any of the following conditions?

Heart Trouble
Pacemaker, Artificial Valves, Bypass
If yes, which one?
Radiation/ Chemotherapy
Stroke
High Blood Pressure
Low Blood Pressure
Rheumatic Fever
Dizziness or Fainting Spells
Frequent Mild or Severe Headaches
Sinusitis, Hay Fever, Asthma
If yes, which one?
Diabetes
Thyroid Condition
Bleeding Disorders
Autoimmune Deficiency Syndrome(AIDS)
Does Your Jaw Click Out of Joint
Artificial Joints
Kidney or Bladder Trouble
Ear Trouble
Epilepsy or Convulsions
Do You Smoke?
Anemia
Tuberculosis
Hepatitis or Jaundice
Venereal Disease/STD's
Cancer
Psychiatric Care
Addiction to Drugs/ Alcohol
If yes, which one?
Have You Ever Been Told You Have Pyorrhea, Periodontal Disease?
Have You Ever Had Periodontal Surgery?
Date

Female Patient:

Are You Pregnant?
Month Due
Are You Taking Birth Control Pills?
Special Diet(?)
Ever Taken Bisphoshonate Drugs, i.e. Aredia, Fosamax. Boniva, Actonel?
Dr. Comments

Are you taking any of the following drugs?

Antibiotics or Sulfa Drugs
Anticoagulants (Blood Thinners)
Medicine For High Blood Pressure
Cortisone (Steroids)
Tranquilizers (Librium, Valium)
Antihistamines
Codeine/Or Pain Medications
Insulin
Digitalis or Drugs For Heart
Nitroglycerin
Decongestant
Other
Please list your specific medications:

Are you allergic or have you reacted adversely to any of the following?

Local Anesthetic (Novocaine Xylocaine )
Penicillin or Antibiotic
Please list
Barbiturates, Tranquilizers, Sleeping Pills
Aspirin or Anti-Inflamatories
Codeine or Similar Narcotic
Other

Please comment on any medical problem not covered above.

ABOUT FINANCIAL ARRANGEMENTS AND DENTAL lNSURANCE

We are committed to provide you the best possible cares. If you have a dental insurance policy, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and understanding of our payment policy.

Payment for services is due at the time services are rendered. We accept cash, checks, American Express, Discover, Mastercard, Visa or Care Credit. We will be happy to process your insurance and in many instances can accept assignment of insurance benefits directly to our office. Should your insurance not assign benefits to our office, you will be responsible for full payment at the time of services and we will happy to process your insurance claim-form for your reimbursement.

We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that:

  1. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. We can only per-estimate your co-payment based on the perception of your policy.
  2. Our fees are generally considered to fall within the acceptable range by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage (such as 50% or 80%) of "U.C.R" is defined as usual, customary and reasonable fees for the region. Thus, our fees are considered usual, customary and reasonable by most companies.
    This statement does not apply to companies who reimburse based an arbitrary "schedule" of fees, which bears no relationship to the current standard and cost of care in this area.
  3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.

We must emphasize that as dental care provider, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we gladly extend to our patients, all charges are your responsibility from the date the service are rendered. We realize temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.

Note:

Returned Checks and balances older than 30 days may be subject to additional collection fees and interest charges of 112% per month. We do not accept out of town checks. Charges may also be incurred for broken appointments and appointments cancelled without a 24 hour notice.

I have read and understand above stated financial arrangements and insurance policies.

Signature:

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

Date: