Patient Information
Dentistry For You
Steve E. Deem, D.D.S.
Sex *
Marital Status: *
Referred by
Method of payment: Payment in full or estimated insurance co-payment is to be paid in full at each appointment. I will pay today's charges in full by:
*All unpaid charges will be subject to finance charges, administration fees and legal costs incurred during collections.
Who will be responsible for the account?

Insurance Information

Dental Insurance - 1st Coverage
Dental Insurance - 2nd Coverage
Smile Evaluation
Do you have specific dental problems?
Do you have dental examinations on a routine basis?
Do you brush and floss daily?
Do your gums bleed?
Do you have spaces you don't like?
Do you like the appearance of your teeth?
Are your teeth all in alignment?
Do you like the color of your teeth?
Are there old fillings or dental work you don't like look at?
Do you ever have clicking/popping/discomfort in your jaw joint?
Do you clinch or grind your teeth?
Have your past dental experiences been positive?
Do you smoke or chew?
Do you snore?
Medical Information
Are you taking any medication
Are you allergic to any of the following
Women Only:
Are you trying to get pregnant? *
Are you nursing? *
Are you taking oral contraceptives? *
Health History
Angina/Chest Pain
Heart Murmur
Congenial Heart Disorder
Scarlet Fever
High Blood Pressure
Tuberculosis
Heart Pace Maker
Epilepsy/Seizure
Rheumatic Fever
Shortness of breath
Leukemia
Chemotherapy
Emphysema
HIV Positive
Hepatitis B or C
Cortisone Medicine
Liver Disease
Ulcers
Kidney Problems
Thyroid Disease
Cold Sores/Fever Blisters
Tumors/Growth
Psychiatric Care
Allergies (Medicines)
Need Premedication
Heart Attack/Failure
Mitral Valve Prolapse
Anemia
Artificial Heart Valve
Heart Surgery
Irregular Heartbeat
Heart Disease
Blood Disease
Diabetes
Asthma
Artificial Joint/Prosthesis
Sickle Cell Disease
Recent blood transfusion
Lung Disease
Cancer
Excessive Thirst
Hepatitis A (infectous)
Pain in jaw joints
AIDS
Drug addiction/Alcoholism
Renal Dialysis
Stroke
Fainting or dizziness
Nervousness
Alzheimer's Disease
Allergies (pollen/dust)
Agree To Terms
I certify that I have read and I understand the questions above. I acknowlege that my questions, if any, about the inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.
I agree to these terms *
Patient name (Parent of Guardian if minor) *
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Fees & Payment
We make every effort to keep the cost down on your dentral treatment. You can help by paying upon completion of each visit. An estimateof the charge for any procedure you may requore will be given to you upon request. If you have dental insurance we will be glad to fill out the proper forms and file them, but please complete the identifying information on this form.
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees and court costs.
Patient signature *
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Authorization
The signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.
Patient Signature 3 *
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I hereby acknowledge that I have received a copy of this practice's Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this notice.
Patient Signature 4 *
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