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Notes
Notes for Dr. Poole & Team
Please do not send any Protected Health Information (PHI)
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Meet the Team
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Patient Information
Name
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First
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Driver's License #
Address
*
Street Address
Address Line 2
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Armed Forces Pacific
State
ZIP Code
Sex
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Age
Birthdate
*
Month
Day
Year
Marital Status
Single
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Minor
Patient Employer
Patient Employer Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Spouse's Name
Spouse's Birthdate
Month
Day
Year
Spouse's Social Security #
Spouse's Employer
Reason for today's visit
How did you learn about Dr. Poole?
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Dental Insurance
Primary Insurance Subscriber's Name
Primary Insurance Subscriber's Birthdate
MM slash DD slash YYYY
Primary Insurance Subscriber's SS#
Primary Insurance Company
Primary Insurance Group #
Secondary Insurance Subscriber's Name
Secondary Insurance Subscriber's Birthdate
MM slash DD slash YYYY
Secondary Insurance Subscriber's SS#
Secondary Insurance Company
Secondary Insurance Group #
Assignment and Release
I certify that I, and/or my dependents(s), have insurance coverage with the above company(ies) and assign directly to Dr. Preston Poole all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Dr. Preston Poole may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Signature of Patient, Parent, Guardian or Personal Representative
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Printed Name
*
First
Last
Date
*
Month
Day
Year
Relationship to Patient
Contact Info
Email
Home Phone
Work Phone
Cell
Spouse's Work
Spouse's Cell
Emergency Contact Name
*
First
Last
Emergency Contact Relationship
Emergency Contact Phone
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Emergency Contact Other Phone
Dental / Health History
Former Dentist
City/State
Date of last dental visit
Date of last dental X-rays
Medical Physician's Name
Phone
Do you require antibiotics before dental treatment?
Do you smoke or use tobacco in any other form?
For Women: Are you taking birth control pills?
Are you pregnant?
Comments
Conditions
Abnormal Bleeding
Artificial Bones/Joints
Artificial Valves
Asthma
Cancer
Chemotherapy
Cholesterol
Congenital Heart Defect
Acid Reflux
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Fainting Spells
Fever Blisters
Glaucoma
Headaches
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia A
Hepatitis A B C
High Blood Pressure
HIV+ / AIDS
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Osteoporosis
Pacemaker
Persistent Cough
Psychiatric Problems
Radiation Treatment
Rheumatic Fever
Sinus Problems
Steroid Therapy
Stroke
Thyroid
Tuberculosis (TB)
List any medications you are currently taking and the correlation diagnosis:
Pharmacy Name
Pharmacy Phone
Allergies
Aspirin
Barbiturates (Sleeping Pills)
Codeine
Iodine
Latex
Local Anesthetic
Penicillin
Sulfa
Other
Rate how happy you are with your smile
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4
3
2
1
10 being most happy
Rate how comfortable you are at a dental office
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9
8
7
6
5
4
3
2
1
10 being most happy
Any Other Comments
Authorization
I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. As a courtesy, we will file your dental insurance. I understand that I a m responsible for payment of services rendered, regardless of my insurance benefit. I understand I am responsible for all late charges after 45 days and collection and attorney fees for unpaid balances.
Initials
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Privacy Practices Acknowledgement
I have reviewed the Notice of Privacy Practices.
Initials
*
BROKEN OR CANCELED APPOINTMENT POLICY
Any appointment that is broken or canceled without a 24 hour notice will be charged a fee of $50 per hour scheduled. We are sympathetic to unavoidable emergencies. In order to avoid your account being charged, our office must receive notice at least 24 hours in advance should it be necessary to reschedule your appointment by phone, voicemail, or email
Initials
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Full Signature
*
Date
*
Month
Day
Year
Preston Poole DMD
Our Location
303 E Highland Ave. Ste 105
Anderson, SC 29621
(864) 226-5058
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