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


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


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:


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

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