EmailMe Form - Seaman Family Dentistry Update

Patient Name: *

Prefix First Last Suffix

If a middle name is necessary to identify you (the patient) please list it with the First Name.

Patient Birthdate: *

MM / DD / YYYY

Contact email: *

Confirm

Who does this email belong to: *

Self / Patient

Mother

Father

Spouse

Other

Please tell us who answers the emails sent to this email address so that we can properly enter it in our patient/account records.

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Please list the address where the patient resides, even if different than the Account Holder.

Patient's Phone Number: *

### - ### - ####

Please check type of phone for this number: *

Cell

Home

Work

Who does this phone belong to: *

Self

Mother

Father

Spouse

Other

Please tell us who answers the emails sent to this email address so that we can properly enter it in our patient/account records.

If Other - Please list who this phone belongs to and relationship to patient:

Alternate Patient Phone Number:

### - ### - ####

Please check type of phone for this number:

Cell

Home

Work

Who does the alternate phone belong to:

Self

Mother

Father

Spouse

Other

Please tell us who answers the emails sent to this email address so that we can properly enter it in our patient/account records.

ACCOUNT HOLDER INFORMATION:

This is the person who will receive any billing statements and is considered financially responsible for all patients on the account. This does NOT have to be the same person as the insured (if you have dental insurance).

Account Holder: *

Prefix First Last Suffix

Who is or should be the account holder for this patient? NOTE: Account holders must be 18 years or older.

Account Holder Address (if different than patient):

Street Address City State / Province / Region Postal / Zip Code Country / Region

This must be a United States address and all billing statements will be sent to this address.

Email Address Account Holder:

Please provide the account holder email address, if it is different than the patient email address.

Account Holder Phone Number:

### - ### - ####

Please check type of phone for this number:

Cell

Home

Work

DENTAL INSURANCE INFORMATION:

Is this patient covered by a DENTAL insurance plan? *

Yes

No

Is the current plan DIFFERENT than the insurance used at the patients last dental visit? *

Yes

No

N/A - have no insurance

If you select YES we will email you the link to our new insurance information form OR if you already have this link in an email or locate it on our site, please complete that form also - only ONE new insurance form needs to be completed for all covered patients.

MEDICAL ALERTS SECTION

Please select all conditions which apply (hold down the control key to select multiple items) and then provide additional information in the box after the choice questions.

ALLERGIES: *

Select ALL that apply (hold down ctrl key for multiple selections), then for any that require additional information, you can provide that information in the next question. YOU MUST MAKE AT LEAST ONE SELECTION FROM THE LIST.

Additional Information regarding ALLERGIES:

Please list the specifics that apply to any of the items you checked above which requested that you "list below".

CURRENT CONDITIONS (Alerts): *

Select all that apply (hold down cntrl key for multiple selections), if none apply, choose NONE OF THE ABOVE from the list.

Past and Present Conditions (Alerts): *

Select all that apply (hold down cntrl key for multiple selections), if none apply, choose NONE OF THE ABOVE from the list.

If Hepatitis is CHECKED above, list type here:

If Adverse Reaction to Dental Anesthetic was checked above, please describe reaction here:

MEDICAL HISTORY

Please select all of the conditions below which you currently HAVE or HAVE HAD in the past - hold down the control key to make multiple selections.

Health Conditions (Past & Present): *

Check all that apply - if NONE apply, check the last item to indicate you have not and do not have any of these conditions.

OTHER HEALTH INFORMATION

Physician Name:

Physician Phone:

### - ### - ####

Are you currently under the care of a physician? *

Yes

No

If YES is checked above, list condition physician is currently treating:

Are you currently taking ANY medication? *

Yes

No

If YES above, please list ALL medications you are taking:

WOMEN ONLY

Skip this section if you are not female.

Are you pregnant?

Yes

No

Possibly

If YES, what is your due date?

Are you currently nursing?

Yes

No

ADDITION INFORMATION

Please provide any additional health information not previously mentioned:

CERTIFICATION

By entering your name below you certify that the information you provided in this form is true and correct to the best of your knowledge.

Person Completing Form: *

First Last

Date Completed:

MM / DD / YYYY

Anemia
Anorexia/Bulimia
Arthritis
Blood Disease
Cancer or Tumors
Damaged Heart Valve
Diabetes
Epilepsy
Fainting/Dizziness/Seizures
Fever Blisters/Herpes
Frequent Headaches
Heart Attack
Heart Disease / Angina
Heart Murmur
High Blood Pressure
Joint Replacement
Low Blood Pressure
Lung Disease
Mental Health Problems
Mitral Valve Prolapse
Prolonged Bleeding
Radiation Treatment
Rheumatic Fever
Sinus Trouble
Stroke
Tuberculosis
HAVE NOT and DO NOT have any of these conditions