Dr. LuAnne M. Curatola Dr. Joseph A. Zagami Patient Information Health HistoryVJ Welcome to our practice: Please take your time to fill out this form completely. The more we learn about you, the better care we are able to provide. We look forward to working with you to maintain a healthy, happy smile. Today's Date First Name Middle Name Last Name I prefer to be called (nickname, etc.): Male Female Address City State Zip: Date of Birth Social Security No. Home Phone Work Phone Cell Phone E-mail Contact Preference Home Work Cell E-mail Emergency Contact Person Relationship Number Whom may we thank for referring you? Dental Insurance: Please make sure that the information given is for you dental insurance, not medical. They are often administered by different insurance companies. Check with you Benefits Coordinator if you are unsure. Primary Carrier Insurance Co. Name Mailing address of claims Group no. (Plan or Policy no.) Insured's I.D.# Insured Person's name (if different from own): Relationship to Patient Date of Birth Insured social security Insured Employer's Name Secondary Carrier (If Applicable) Insurance Co. Name Mailing address of claims Group no. (Plan or Policy no.) Insured's I.D.# Insured Person's name (if different from own): Relationship to Patient Date of Birth: Insured social security Insured Employer's Name 330 W. 58th. St. Suite 605   NY, NY 10019 212-586-3585 dental@CurZag.com www.creatingNYCsmiles.com Health History Please check if you have had any of the following: Yes No AIDS/HIV Alcohol/Drug Abuse Allergies or Hives Anemia Arthritis/Rheumatism Artificial Heart Valve Artificial Bones/Joints Asthma Blood Disease Blood Transfusion Bruise Easily Cancer/Chemotherapy Chest Pain Cold Sores/Herpes Colitis Contact Lenses Cortisone Medicine Diabetes Diet (Special/Restricted) Yes No Difficulty Breathing Emphysema Epilepsy or Seizures Fainting or Dizzy Spells Frequent Headaches Glaucoma Hay Fever Heart (Surgery, Disease, Attack) Heart Pacemaker Heart Murmur Hemophilia/Abnormal Bleeding Hepatitis If Yes Hepatitis A B C High/Low Blood Pressure Hospitalized for Any Reason Jaundice Kidney Trouble Liver Disease Yes No Lupus Mitral Valve Prolapse Nervousness/Anxiety Neurological Disorders Psychiatric/Psychological Care Radiation Therapy Rheumatic/Scarlet Fever Shingles/Chicken Pox Sickle Cell Disease/Traits Sinus Trouble Snoring/Sleep Apnea Stomach Problems/Ulcers Stroke Swollen Ankles Thyroid Problems Tuberculosis (TB) Tumors Venereal Disease/STD/HPV Other Conditions not Listed Have you been Hospitalized or under the care of a medical doctor during the past 2 years? Yes No If yes, for what? Hospital or Physician's Name: Phone Number: Are you currently taking any medications or drugs? (including regular doses of over-the-counter medicines, vitamins and supplements Yes No If Yes, please list: Do you use Tobacco? Yes No Do you use Alcohol? Yes No Frequency? Do you use any other Controlled Substance Yes No Women: Are you pregnant or think you may be pregnant? Yes No Are you nursing? Yes No Are you taking birth control pills? Yes No Are you aware of having an allergic (or adverse) reaction of the following: Yes No Anesthetics Aspirin Codeine Erythromycin Yes No Iodine Jewelry/Metals Latex Penicillin or Other Antibiotics Yes No Sedative Sulfa Drugs Tetracycline Other Patient Acknowledgement and HIPAA Update Please read and sign below: I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentists or any other member of their staff responsible for any errors or omissions that I may have made in the completion of this form. Signature of Patient or Guardian Date In an effort to comply with Federal Privacy Practices, please read and sign below: I certify that I am aware of the Federal Privacy Practices, and/or have been given a notice of such from the office of Drs. Curatola & Zagami. I understand that I will receive postcards, letters, internet correspondences, and phone calls at any of the contact information I provide to this practice. I also understand that I must personally notify the practice should I not wish to receive any of the above correspondences or notifications. Signature of Patient or Guardian Date 330 W. 58th. St. Suite 605   NY, NY 10019 212-586-3585 dental@CurZag.com www.creatingNYCsmiles.com Dental History Reason for visit: Approximate date of last dental exam: Last teeth cleaning: Last dental x-rays: IMPORTANT: If you have had dental x-rays taken within the last year, please ask your previous dentist to e-mail them in JPEG format to: dental@CurZag.com Do you have any dental questions or concerns you'd like to discuss? Are you currently in pain? Yes No If so, please describe Have you ever had any serious problem associated with previous dental treatment or dental emergencies? Yes No If so, please describe How often do you brush your teeth? times a . How often do you floss? times a . What type of tooth brush do you use? Manual Powered Do you ever feel (or have you ever been told) that you don't have fresh breath? Yes No Do you avoid brushing any part of your mouth because of pain? Yes No If yes, what part? Which types of food cause you twinges of pain Hot Cold Sweet Sour None Do your gums feel tender or swollen? Yes No Do you have any cold sores / mouth sores / mouth ulcers? Yes No If so, please describe Do you chew on only one side of your mouth? Yes No If so, explain: Do you clench or grind your jaws while sleeping or during the day? Yes No Do your jaws ever feel tired? Yes No Do you still have your wisdom teeth? Yes No Do you snore when sleeping? Yes No Have you ever been diagnosed with Sleep Apnea? Yes No Previous dentist's name: Phone: City: Email: Why are you changing dentists? Level of anxiety about seeing the dentist: (least) 12345 (most) If over 3, please explain: Have you ever been treated for any of the following? Yes No Yes No Periodontal disease/gum treatment Jaw joint pain (TMJ/TMD) Orthodontic treatment/braces Teeth grinding or bite adjustments Oral surgery/teeth extractions Dental Implants Bite plate/mouth guard Serious injury to the mouth or head Smile Analysis Are you delighted with your smile? Yes No Please rate your smile from 1 to 10 (1= I hate my smile, 10=awesome) Would you like to have whiter teeth? Yes No Would you like to have straighter teeth? Yes No If you could change any thing about your smile, what would it be? (please check any of the following that apply) Color of your teeth Too much or too little of teeth show when you smile Gaps between your teeth Size/Shape of your teeth Too much or too little of gum shows when you smile Alignment of your teeth Other What (if any) personal or professional benefit might you gain if you had a gorgeous smile? Please add anything you feel is important: 330 W. 58th. St. Suite 605   NY, NY 10019 212-586-3585 dental@CurZag.com www.creatingNYCsmiles.com Financial Options and Obligations We offer a wide range of financial options in order to pay for your dental treatment. We can receive payment towards your account from any insurance plan in which you can choose your own dentist (PPO,PDO,Premier,etc.). We do this as a courtesy to you, our patient. While we do our best to estimate your "out-of-pocket" expense based up on the information we receive from your plan, we are not resoonsible for any denial or reduction of payment as determined by your insurance. We can never guarantee payment from your insurance. After your dental insurance as paid for dental services rendered, you may have an outstanding balance. This balance may include any deductibles, copayments, denials, and non-covered services. For balance owed, we require a credit card authorization. FORMS OF PAYMENT ON BALANCE DUE In order to facilitate access to the very best health care possible, you may choose from any of the following: Cash, Visa, MasterCard, AmericanExpress, Discover, MoneyOrder, Personal Checks, or CareCredit. FINANCIAL ARRANGEMENTS Several in-office payment arrangements are available for account balances. All fees will be disclosed to you and financial arrangements discussed and confirmed prior to treatment. Pay as You Go: You may choose to pay your obligation with cash, check or creditcard at the time of your visits Prepayment in Full: A Prepayment Courtesy will be given for payment in full before or at the first treatment visit (does not include CareCredit payment) Split Payment: One half or one third of the total treatment is due at the preparation visit; the second and third payments due in the middle of treatment; and final paymentat the cementation visit of the dental appliance. CareCredit: With fast online approval CareCredit can help you get the healthy, radiant smile you've always wanted with the card designed specifically for your dental needs. CareCredit offers No Interest and low monthly payment options, no up-front costs, no prepayment penalties, and no annual fees. CareCredit is a medical/dental line of credit, and can be subject to interest fees as set forth by CareCredit. Pre-approval is required. Go to www.carecredit.com for complete information and pre-approval. Please Read and Sign the Following: I understand that if I become delinquent on my account, my account will be turned over to a collection agency, and I will subsequently be reported to the credit bureaus. In case of total default, I promise to pay any collection costs and attorney fees incurred to collect on this account. I certify that I have read, fully understand, and accept the above financial policy. Signature of Patient or Guardian Date Please enter code above in the field below.