Patient Information


    Personal Details

    Address Details

    Medical history

    Although Dental personnel treat the area in and around your mouth, you mouth is a part of your entire body. Please inform us of any health problems you may have or medication you are taking.

    Are you under the care of a physician right now?
    Have you ever been hospitalized or had a major operation?
    Have you ever had a serious head or neck injury?
    Are you taking any medications, pills, or drugs?
    Do you take, or have you taken, Phen-Fen or Redux?
    Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
    Are you on a special diet?
    Do you use tobacco?
    Women: Are you…….
    Are you allergic to any of the following?
    Do you use Controlled Substances

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

    Cortisone Medicine
    Radiation Treatment
    Hepatitis A
    Recent Weight Loss
    Drug Addiction
    Hepatitis B or C
    Renal Dyalysis
    Easily Winded
    Rheumatic Fever
    High Blood Pressure
    Epilepsy or Seizures
    High Cholesterol
    Scarlet Fever
    Artificial Heart Valve
    Excessive Bleeding
    Hives or Rash
    Artificial Joint
    Excessive Thirst
    Sickle Cell Disease
    Fainting Spells/Dizziness
    Irregular Heartbeat
    Blood Disease
    Frequent Cough
    Kidney Problems
    Spina Bifida
    Blood Transfusion
    Frequent Diarrhea
    Stomach/Intestinal Disease
    Breathing Problems
    Frequent Headaches
    Liver Disease
    Bruise Easily
    Genital Herpes
    Low Blood Pressure
    Swelling of Limbs
    Lung Disease
    Thyroid Disease
    Hay Fever
    Mitral Valve Prolapse
    Chest Pains
    Heart Attack/Failure
    Cold Sores/Fever Blister
    Heart Murmur
    Pain in Jaw Joints
    Congenital heart Disorder
    Heart Pacemaker
    Parathyroid Disease
    Heart Trouble/Disease
    Psychiatric Care
    Venereal Disease
    Yellow Jaundice
    Have you ever had any serious illness not listed?

    HIPPA form & Release of information

    We attempted to obtain written acknowlegement of reciept of notice of privacy practices but:*

    Financial and cancellation policy

    Corwin Family Dentistry

    Cancellations and Failed Appointments

    We are committed to providing the best dental care to our patients and to keeping your costs as low as possible. In order to accomplish this, it is imperative that appointments that are made with us are kept. If you are unable to keep an appointment, we require 24hours notice, so that other patients who need to be seen can be scheduled.
    If an appointment is missed without any notice, or for excessively canceling appointments with less than 24hours notice, there will be a $100 charge and a current credit card will be required to be on file. If a second appointment is missed or cancelled, the full fee for the appointment will be charged to your card.

    Financial Policy

    Each patient will be given a treatment plan for any appointment that is planned. The treatment plan details the cost of our services and an estimate of how much insurance will contribute. If you have any questions about the cost of your treatment, please ask before scheduling your appointment. Payment in full for work done is required at the time or the appointment, either by cash, check or credit card.

    If your insurance has not paid on a claim within 60 days, you will be responsible for the unpaid portion and we will send a bill for that amount. If the payment from insurance comes to us after you’ve paid it, we will send you a reimbursement check.

    Your Insurance

    We are happy to help answer general questions about dental insurance. However, we must stress that your policy is an agreement between you and your insurance company, and that we are a third party to that contract. If you have specific questions about your policy, you can call your insurance company: They will be able to give you more specific information.
    If you have questions about any of these policies, please ask for clarification prior to your appointment.