. Patient History Form for the Office of Robert E. Gatens, D.D.S.
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CIRCLE ANY OF THE FOLLOWING
WHICH YOU HAVE HAD OR HAVE:
  Heart Trouble   Hepatitis
  Heart Murmur   Sinus Trouble
  High Blood Pressure     Abnormal Bleeding
  Rheumatic Fever   Epilepsy
  Anemia   Arthritis
  Asthma   Venereal Disease
  HIV   Herpes
  Diabetes   Radiation Treatment  
  Tuberculosis   Stroke
  Ulcers   Cancer

When was your last
complete physical examination? _____________________

  • Physician's Name __________________________

  • Physician's Telephone ______________________

Allergies To:

  • Penicillin     Codeine     Novocaine

  • Others: ____________________

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In Case of Emergency, Who Should Be Notified?

  • Name ___________________________________   Telephone ____________________

  • Name ___________________________________   Telephone ____________________

I authorize the dentist treating me to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care.

Signature __________________________________   Date _________________________

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FINANCIAL POLICY, PLEASE READ AND SIGN

I understand that I am financially responsible to Doctor Gatens for all charges incurred by me and/or my dependents.   I agree that in the event my account is past due for 60 days from the date of services, and is turned over to an attorney for collection, I will be liable for collection fees in the amount of 1/3 of the principal balance (minimum $50.00) plus all court costs.   I will pay interest on accounts past due 60 days or more at the rate of 1.5% per month (minimum $2.00).   There will be a $25.00 charge for any returned checks.

Signature _____________________________________   Date _______________________

 
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IF YOU HAVE INSURANCE THAT YOU WISH US TO FILE, THEN PLEASE READ AND SIGN

I hereby assign all medical, dental and/or surgical benefits to which I am entitled for this service to Doctor Gatens.  This assignment will remain in effect until revoked by me in writing.  A photocopy of this assignment is to be considered as valid as an original.  I understand that I am financially responsible for any and all remaining balance of my and/or my dependents' account not paid by said insurance within 45 days.  I hereby authorize the release of all information necessary to secure payment.

Signature _____________________________________   Date ______________________

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1 January 2007