Dr. Veronica Cooper, DDS • 1628 30th Street NW • Bemidji, MN 56601 • 2 1 8 . 4 4 4 . 2 0 0 4 • BlackBearFamilyDental@gmail.com

Black Bear Dental letterhead.indd 1 10/4/18 8:29 AM

PATIENT INFORMATION

*IF CHILD, PROVIDE PARENT/GUARDIAN INFORMATION:

EMERGENCY INFORMATION

EMPLOYMENT INFORMATION (IF MINOR, PARENT/GUARDIAN INFORMATION)

INSURANCE INFORMATION

DATE: ____________________ NEW PATIENT UPDATEPATIENT: ______________________________________________________________________________________ LAST FIRST MI PREFERRED MALE FEMALE STUDENT SCHOOL: _________________ SINGLE MARRIED DIVORCED OTHER:

PATIENT DATE OF BIRTH: ____________________ PATIENT SSN: ____________________ADDRESS: ____________________________________________________________________________________ ADDRESS LINE 1

HOME: ______________________ ADDRESS LINE 2 CELL: _______________________ WORK: ____________ EXT: ______ CITY ST ZIP CODE E-MAIL: ___________________________________________________________________________________WHOM MAY WE THANK FOR REFERRING YOU? ______________________________________________________

PARENT/GUARDIAN NAME(S): ___________________________ DATE OF BIRTH: __________SSN: ___________

ADDRESS: _________________________________________________ PHONE: __________________________

IN CASE OF EMERGENCY, PLEASE PROVIDE INFORMATION FOR THE NEAREST RELATIVE OR DESIGNATED CONTACT PERSONS NOT AT THE PATIENT’S ADDRESS.

NAME RELATIONSHIP TELEPHONE

Employer: ________________________________________ Occupation: _______________________________

Address: ___________________________________________________________ ADDRESS LINE WORK PHONE: ________________ ext. _____________ _____________________________________________________________________________________________ ADDRESS LINE 2 CITY STATE ZIP

PRIMARY PRIMARY INSURANCESUBSCRIBER: ______________________________________ CARRIER:___________________________________ LAST FIRST

SUBSCRIBER DATE OF BIRTH: __________________________ ID NUMBER: ________________________________

SUBSCRIBER EMPLOYER: _____________________________ GROUP/POLICY NUMBER: _____________________

SUBSCRIBER SSN: ___________________________________ TELEPHONE NUMBER: ________________________

PATIENT RELATIONSHIP TO SUBSCRIBER: SELF SPOUSE CHILD OTHER:

PRIMARY PRIMARY INSURANCESUBSCRIBER: ______________________________________ CARRIER:___________________________________ LAST FIRST

SUBSCRIBER DATE OF BIRTH: __________________________ ID NUMBER: ________________________________

SUBSCRIBER EMPLOYER: _____________________________ GROUP/POLICY NUMBER: _____________________

SUBSCRIBER SSN: ___________________________________ TELEPHONE NUMBER: ________________________

PATIENT RELATIONSHIP TO SUBSCRIBER: SELF SPOUSE CHILD OTHER:

THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE MY INSURANCE BENEFITS BE PAID DIRECTLY TO THE PHYSICIAN. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY BALANCE. I ALSO AUTHORIZE BLACK BEAR FAMILY DENTAL OR INSURANCE COMPANY TO RELEASE ANY INFORMATION REQUIRED TO PROCESS MY CLAIMS.

PATIENT/GUARDIAN SIGNATURE: __________________________________________________________ DATE: _________________________

EMERGENCY INFORMATION

Dr. Veronica Cooper, DDS • 1628 30th Street NW • Bemidji, MN 56601 • 2 1 8 . 4 4 4 . 2 0 0 4 • BlackBearFamilyDental@gmail.com

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PRIMARY PHYSICIAN INFORMATION

MEDICAL HISTORY

Y N

Y NY N

FEMALE PATIENTS: Y N CURRENTLY NURSING? Y N CURRENTLY PREGNANT? DUE DATE:

ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY): NONE

ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):

MEDICATION INFORMATIONALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY): NONE

Y N ARE YOU TAKING ANY PRESCRIPTION OR DAILY OVER THE COUNTER MEDICATIONS/DRUGS? IF YES, LIST BELOW:DRUG NAME DOSAGE REASON PRESCRIBED

DO YOU KNOW OF ANY REASON WHY ROUTINE DENTAL PROCEDURES MIGHT POSE A RISK TO YOU, OR STAFF, OR OTHER PATIENTS? Y N IF YES, PLEASE DESCRIBE:

THERE ANYTHING IMPORTANT ABOUT YOUR MEDICAL CONDITION WE HAVE NOT ASKED? Y NIF YES, PLEASE DESCRIBE:

ACID REFLUXADHAAIDS/HIVANEMIAFREQUENT HEADACHESANXIETY DISORDERAUTISM/ASPERGER’SARTIFICIAL JOINTSARTHRITISASTHMAARTIFICIAL HEART VALVEGLAUCOMAFOOD ALLERGIES:

BULIMIAHEART ATTACKHEART DISEASEHEART MURMURHEPATITISHIGH BLOOD PRESSUREKIDNEY DISEASELIVER DISEASEMITRAL VALVE PROLAPSEMONONUCLEOSISBLEEDING DISORDERHEARING PROBLEMS

ASPIRINANESTHETIC - LOCALOTHER - PLEASE:

CODEINELATEX

NITROUS OXIDE SEDATIONMETAL SENSITIVITY

SULFA DRUGSPENICILLIN/OTHER ANTIBIOTICS

OTHER

ANTIBIOTICS/SULFA DRUGSBLOOD THINNERSINSULINOTHER DIABETIC MEDICATIONSORAL/IV BISPHORATES (OSTEOPOROSIS, PAGET’S DISEASE)

PHYSICIAN: ______________________________________________ TELEPHONE: __________________________CLINIC/FACILITY _______________________________________________________________________________

GENERAL HEALTH: EXCELLENT GOOD FAIR POOR

HAVE YOU BEEN UNDER THE CARE OF A MEDICAL DOC TOR DURING THE PAST TWO YEARS?IF SO, FOR WHAT REASON?

USE TOBACCO IN ANY FORM? IF YES, TYPE:

DOES YOUR PHYSICIAN (DOCTOR) REQUIRE YOU TO PRE-MEDICATE PRIOR TO DENTAL PROCEDURES?

ANOREXIACANCER/MALIGNANCYCEREBRAL PALSYDRUG ADDICTION/ALCOHOLISMCHICKEN POXCONVULSIONSDEPRESSIONDIABETESDIZZINESS/FAINTINGEPILEPSY/SEIZURESPACEMAKERCOLDSORES/FEVER BLISTERS

ANTIHISTAMINES/ALLERGYCANCER/CHEMO MEDICATIONSNITROGLYCERINRECREATIONAL DRUGS

DAILY ASPIRINCORTISONE/STEROIDSORAL CONTRACEPTIVESTHYROID MEDICATIONS

BLOOD PRESSURE MEDICATIONSHEART MEDICATATION/DIGITALISTRANQUILIZERSOTHER (PLEASE LIST)

Dr. Veronica Cooper, DDS • 1628 30th Street NW • Bemidji, MN 56601 • 2 1 8 . 4 4 4 . 2 0 0 4 • BlackBearFamilyDental@gmail.com

Black Bear Dental letterhead.indd 1 10/4/18 8:29 AM

DENTAL HISTORY

Y NY NY NY NY NY N

Y NY NY NY NY NY N

IF CHILD/MINOR: PLEASE ANSWER THE FOLLOWING QUESTIONS:Y N

Y N

,

PREVIOUS DENTIST INFORMATION

DENTIST: __________________________________________ TELEPHONE: _______________________________________

CLINIC NAME/CITY: ___________________________________________________________________________________________

REASON FOR CHANGING: ______________________________________________________________________________________

DATE OF LAST DENTAL VISIT: ___________________________________________________________________________________

HOW OFTEN DO YOU BRUSH YOUR TEETH? _______________________________________ FLOSS? ____________________

DO YOUR GUMS BLEED? ___________ WHEN? BRUSHING FLOSSING OTHER:

I AM UNCOMFORTABLE SHOWING MY TEETH WHEN I SMILE.

I AM UNHAPPY WITH MY CROWNS OR FILLINGS.

MY GUMS OR TEETH ARE SENSITIVE

I AM CONCERNED THAT MY GUMS ARE RECEDING

I CLENCH OR GRIND MY TEETH

I HAVE QUESTIONS ABOUT THE BENEFITS OF DENTAL IMPLANTS

I AM UNHAPPY WITH THE APPEARANCE OF MY TEETH

I FEEL THAT MY TEETH COULD BE WHITER

I AM INTERESTED IN STRAIGHTENING MY TEETH

I FEEL MY TEETH ARE TOO LONG OR TOO SHORT

I AM ANXIOUS OR FEARFUL OF TREATMENT.

IS THERE SOMETHING ELSE HOLDING YOU BACK FROM THE PERFECT SMILE? (EXPLAIN BELOW)

THE MOST IMPORTANT CONCERNS REGARDING MY DENTAL TREATMENT ARE:

WHAT FACTORS ARE MOST IMPORTANT FOR YOUR SATISFACTION WITH OUR OFFICE?

ANY ADDITIONAL CONCERNS/COMMENTS?

ANY MOUTH HABITS? (THUMB SUCKING, TONGUE THRUSTING, NAIL BITING, MOUTH BREATHING, NURSING/BOTTLE HABITS, PACIFIER, ETC.)

DO YOU HELP YOUR CHILD WITH BRUSHING AND FLOSSING? IF YES, HOW OFTEN?

HEALTH QUESTIONNAIRE ACKNOWLEDGEMENT AND CONSENT TO PROCEED: I CERTIFY THAT THE ANSWERS TO THE HEALTH QUESTIONS ARE

ACCURATE AND CORRECT TO THE BEST OF MY KNOWLEDGE. SINCE A CHANGE OF MEDICAL CONDITION OR MEDICATIONS CAN AFFECT DENTAL

TREATMENT, I UNDERSTAND THE IMPORTANCE OF THE AGREE TO NOTIFY THE DENTIST OF NAY CHANGES AT ANY SUBSEQUENT APPOINTMENT. I

UNDERSTAND THAT THE ADMINISTRATION OF LOCAL ANESTHETIC MAY CAUSE AN UNTOWARD REACTION OR SIDE EFFECTS, WHICH MAY INCLUDE, BUT ARE

NOT LIMITED TO BRUISING, HEMATOMA, CARDIAC STIMULATION, TEMPORARY OR RARELY, PERMANENT NUMBNESS, AND MUSCLE SORENESS. I

UNDERSTAND THAT AS A RESULT OF DENTAL TREATMENT, INCLUDING PREVENTATIVE PROCEDURES SUCH AS CLEANING AND BASIC DENTISTRY, AS WELL

AS FILLINGS OF ALL TYPES, TEETH MAY REMAIN SENSITIVE OR EVEN POSSIBLY QUITE PAINFUL BOTH DURING AND AFTER COMPLETION OF TREATMENT.

GUMS AND SURROUNDING TISSUES MAY ALSO BE SENSITIVE OR PAINFUL DURING AND OR AFTER TREATMENT.

CONSENT FOR TREATMENT: I HERBY GRANT AUTHORITY TO THE DENTIST AT BLACK BEAR FAMILY DENTAL TO ADMINISTER ANY TREATMENT OR TO

ADMINISTER SUCH ANESTHETICS, ANALGESICS, SEDATIVES AND NITROUS OXIDE SEDATION, AND TO PERFORM SUCH OPERATIONS AS MAY BE DEEMED

NECESSARY OR ADVISABLE IN MY DIAGNOSIS AND TREATMENT. I HAVE READ THE ABOVE TERMS AND CONDITIONS AND CONSENT FOR TREATMENT AND

FULLY AGREE TO THEIR CONTENT. IDO VOLUNTARILY ASSUME MANY AND ALL POSSIBLE RISKS, INCLUDING THE RISK OF SUBSTANTIAL AND SERIOUS HARM,

IF ANY, WHICH MAY BE ASSICATED WITH GENERAL PREVENTATIVE AND OPERATIVE TREATMENT PROCEDURES IN HOPS OF OBTAINING THE POTENTIAL

DIRSIRED RESULTS, WHICH MAY OR MAY NOT BE ACHIEVED, FOR MY BENEFIT.

SIGNATURE OF PATIENT/GUARDIAN DATE RELATION TO PATIENT