Welcome! Thank you for choosing our dental practice. Our
Team takes pride in providing excellent quality services to
ensure that your visit is a pleasant one. Our goal is to provide
you with state-of-the-art dentistry in a professional and caring
environment.
For your First Time Patient experience, you can expect the
“Next Level in Patient Care” with the most current dental
techniques. You will receive a thorough examination followed
by a personalized consultation to discuss your options. Therefore, please anticipate a two hour visit.
Included is our Patient Profile form. Please complete the form
prior to your visit and return it by mail or fax to the following:
Dr. Fary Yassamy, DDS, Inc.
825 Huntington Drive
San Marino, CA 91108
Or
Fax 626-441-3024
We are looking forward to meeting you.
Dr. Yassamy and Team
Welcome
The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral
health. Please fill out this form completely. The better we communicate, the better we can care for you.
ABOUT YOU
Today’s Date:
E-mail Address:
I prefer to be called:
Name:
Last
First
Birthdate:
Age:
Mi
Mr
Mrs
Ms
❑ Male ❑ Female
Dr
Social Security #:
❑ Single ❑ Married ❑ Divorced ❑ Widowed ❑ Separated
Home Address:
Street/PO Box
City
Home Phone #:
Pager/Car #:
State
Work Phone #:
Where & when are best times to reach you?
Ext:
Zip
Driver License #:
Whom may we thank for referring you?
Other family members seen by us:
How long there?
Employer:
Occupation:
Employer’s Address:
Street/PO Box
City
State
Zip
Neighbor or Relative not living with you
His / Her Name:
Relation:
Work Phone #:
Home Phone #:
City
State
Address:
Street
Zip
Person Responsible for Account if other than yourself
Name:
Relation:
Employer:
Home Phone #:
Social Security #:
Work Phone #:
Ext:
Drivers License #:
Billing Address:
Street/PO Box
City
State
Zip
SPOUSE INFORMATION
His / Her Name:
Birthdate:
Employer:
Work Phone #:
Social Security #:
Ext:
Drivers License #:
INSURANCE INFORMATION
Medical Coverage? ❑ Yes ❑ No
Primary Insurance
Insurance Co. Name:
Dental Coverage? ❑ Yes ❑ No
Phone #:
Orthodontic Coverage? ❑ Yes ❑ No
Group # (Plan, Local or Policy #):
Insurance Co. Address:
Street/PO Box
Insured’s Name:
City
Insured’s Social Security #:
Insured’s Employer:
State
Insured’s Birthdate:
Employer’s Address:
Street/PO Box
Secondary Insurance
Zip
Relation:
Medical Coverage? ❑ Yes ❑ No
Insurance Co. Name:
City
Dental Coverage? ❑ Yes ❑ No
Phone #:
State
Zip
Orthodontic Coverage? ❑ Yes ❑ No
Group # (Plan, Local or Policy #):
Insurance Co. Address:
Street/PO Box
Insured’s Name:
Insured’s Employer:
City
Insured’s Social Security #:
State
Insured’s Birthdate:
Zip
Relation:
Employer’s Address:
Street/PO Box
City
State
Zip
CONTINUED
CONTINUED ON
ON BACK
BACK
DENTAL HISTORY
Why have you come to the dentist today?
Do your gums ever bleed? ❑ Yes ❑ No
Ever Itch? ❑ Yes ❑ No
Have you ever had periodontal disease?
❑ Yes ❑ No
❑ Yes ❑ No
Are you currently in pain?
❑ Yes ❑ No
Do you have mobility in your teeth?
Do you need to be premedicated before dental treatment?
❑ Yes ❑ No
Are your teeth sensitive to heat, cold, or anything else?
Do you still have wisdom teeth?
Have you experienced problems associated with
any previous dental work?
Your current dental health is
Do you floss daily?
If yes, why?
❑ Yes ❑ No
Do you now or have you ever experienced pain / discomfort
in your jaw joint (TMJ / TMD)?
❑ Previous ❑ Present Dentist:
Brush daily?
Type of bristles on your toothbrush?
❑ Hard
Why did you leave your previous dentist?
What did you like most & least about any dentist you have seen?
❑ Yes ❑ No
❑ Medium
❑ Soft
Are you happy with the way your smile looks? ❑ Yes ❑ No
How long do you use a toothbrush before replacing it?
Do you use anything in addition to your brush and floss?
Last Visit Date:
❑ Yes ❑ No
❑ Good ❑ Fair ❑ Poor
❑ Yes ❑ No
❑ Yes ❑ No
If not, what would you change?
❑ Yes ❑ No
If yes, what?
MEDICAL HISTORY
Do you have a personal physician?
Do you smoke or use tobacco in any other form?
❑ Yes ❑ No
Physician’s Name:
❑ Yes ❑ No
Are you allergic to any of the following?
Y
Y
Y
Y
Address:
Street
City
Phone #:
State
Zip
Date of last visit:
❑ Good ❑ Fair ❑ Poor
Your current physical health is:
Are you currently under the care of a physician?
N
N
N
N
Aspirin
Barbiturates
Codeine
Dental Anesthetics
Y
Y
Y
Y
N
N
N
N
Erythromycin
Jewelry
Latex
Penicillin
Y
Y
Y
Y
N
N
N
N
Sedatives
Sulfa Drugs
Tetracycline
Other
Please list additional drugs that cause allergic reactions:
❑ Yes ❑ No
Please explain:
For Women: Are you taking birth control pills?
Have you ever taken Fosamax, or any other Bisphosphonate? ❑ Yes ❑ No
Have you ever taken Phen-Fen? Also known as Redux or Pondimin. ❑ Yes ❑ No
If so, when _________________.
Are you pregnant? ❑ Unsure
❑ Yes
❑ Yes ❑ No
❑ No
Week #:
Are you nursing?
Yes
No
Are you taking any of the following?
Y
Y
Y
N Acetaminophen
N Antibiotics
N Antihistamines
Y
Y
Y
N Aspirin
N Blood Thinners
N Blood Pressure Meds
Y
Y
Y
N Cold Remedies
N Digitalis/Heart Meds
N Insulin/Diabetes Drugs
Are you taking any prescription/over-the-counter-drugs not listed above? ❑ Yes ❑ No
Y
Y
Y
N Nitroglycerin
N Recreational Drugs
N Steroids/Cortisone
Y
Y
N Thyroid Medicine
N Tranquilizers
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
If yes, please list each one:
Do you or have you experienced the following?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Abnormal Bleeding
Alcohol Abuse
Anemia
Arthritis
Artificial Bones/Joints
Artificial Valves
Asthma
Blood Transfusion
Cancer
Chemotherapy
Chicken Pox
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Fainting Spells
Fever Blisters
Glaucoma
Hay Fever
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Headaches
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis
Herpes
High Blood Pressure
HIV +/AIDS
Hospitalized for any reason
Kidney Problems
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Persistent Cough
Psychiatric Problems
Radiation Treatment
Rheumatic Fever
Scarlet Fever
Seizures
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tonsillitis
Tuberculosis (TB)
Ulcers
Venereal Disease
Please list any serious medical condition(s) that you have experienced:
AUTHORIZATIONS
I affirm that the information I have given is correct to the best of my knowledge. It will
be held in the strictest confidence and it is my responsibility to inform this office of any
changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need. My method of payment will be
.
Signature
Date
I certify that I am covered by
Insurance Co. and
I assign directly to Dr. Yassamy all insurance benefits, otherwise payable to me. I
understand that I am responsible for payment of services rendered and also
responsible for paying any co-payment and deductible that my insurance does not
cover. I hereby authorize the dentist to release all information necessary to secure
the payment of benefits. I authorize the use of this signature on all my insurance
submissions, whether manual or electronic.
PAYMENT IS DUE AT TIME OF SERVICE
Our office is HIPAA compliant and is committed to meeting or exceeding the
standards of infection control mandated by OSHA, the CDC and the ADA.
FORM # YASSAMY-CUST
Signature
www.informsonline.com
Date
© 2010
1-800-722-4884