Patient Information - Southampton Aesthetic Dentistry


dental service in Southampton

Southampton Aesthetic Dentistry’s dental philosophy is based on making you feel at ease throughout your course of treatment. Our comfort-enhancing amenities include a music for your relaxation and enjoyment.

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Please Fill out our Medical History Form

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Please Fill out our New Patient

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Please Fill out our Notice of Privacy Practice Form

Medical History Form

    Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

    Are you under a physician's care now?

    Have you ever been hospitalized or had a major operation?

    Have you ever had a serious head or neck injury?

    Are you taking any medications, pills, or drugs?

    Do you take, or have you taken, Phen-Fen or Redux?

    Have you ever taken Fosamax, Boniva, Actonel or any other
    medications containing

    Are you on a special diet?

    Do you use tobacco?

    Do you use controlled substances?

    Women Are You...

    Are you allergic to any of the following?

    Do you have, or have you had, any of the following?

    AIDS/HIV Positive:

    Cortisone Medicine:


    Radiation Treatments:

    Alzheimer's Disease:


    Hepatitis A:

    Recent Weight Loss:


    Drug Addiction:

    Hepatitis B or C:

    Renal Dialysis:


    Easily Winded:


    Rheumatic Fever:



    High Blood Pressure:



    Epilepsy or Seizures:

    High Cholesterol:

    Scarlet Fever:

    Artificial Heart Valve:

    Excessive Bleeding:

    Hives or Rash:


    Artificial Joint:

    Excessive Thirst:


    Sickle Cell Disease:


    Fainting Spells/Dizziness:

    Irregular Heartbeat:

    Sinus Trouble:

    Blood Disease:

    Frequent Cough:

    Kidney Problems:

    Spina Bifida:

    Blood Transfusion:

    Frequent Diarrhea:


    Stomach/Intestinal Disease:

    Breathing Problems:

    Frequent Headaches:

    Liver Disease:


    Bruise Easily:

    Genital Herpes:

    Low Blood Pressure:

    Swelling of Limbs:



    Lung Disease:

    Thyroid Disease:


    Hay Fever:

    Mitral Valve Prolapse:


    Chest Pains:

    Heart Attack/Failure:



    Cold Sores/Fever Blisters:

    Heart Murmur:

    Pain in Jaw Joints:

    Tumors or Growths:

    Congenital Heart Disorder:

    Heart Pacemaker:

    Parathyroid Disease:



    Heart Trouble/Disease:

    Psychiatric Care:

    Venereal Disease:

    Have you ever-had any serious illness not listed above?

    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

    Signature of Patient, Parent or Guardian:

    Patient Information

      If Student

      Dental Insurance Information:

      Do you have any additional insurance? If so, please complete the following section

      Patient Dental History:

      Do your gums bleed while brushing or flossing?

      Are your teeth sensitive to hot or cold liquids/food?

      Do you feel pain in any of your teeth?

      Do you have any sores or lumps in/near your mouth?

      Do you have a concern with snoring?

      Do you have frequent headaches?

      Do you clench or grind your teeth?

      Have you ever had any prolonged bleeding following extractions?

      Do you wear dentures/partials?

      Name and Location of Previous Dentist

      Do you like your smile?

      Have you ever had orthodontic treatment?

      Have your teeth shifted since?

      Signature of Patient, Parent or Guardian:

      Signature of patient/responsible party certifies that you have read and completed the above information to the best of my knowledge. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

      Please Fill out our Notice of Privacy Practice Form

        I have been given a copy of Southampton Aesthetic Dentistry. Notice of Privacy Practices (”Notice”), which describes how my health information is used and shared. I understand that the Practice has the right to change this notice at any time. I may obtain a copy by contacting the Practice Privacy Offier.

        My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

        For Facility Use Only: Complete this section if you are unable to obtain a signature If the patient or personal representative is unable or unwilling to sign this Acknowledgment, or the Acknowledgment is not signed for any other reason, state the reason:


        At Southampton Aesthetic Dentistry’s we believe that cost shouldn’t be an obstacle to dental health. We offer a 10 percent discount to senior citizens if treatment is received on the day of service. We accept CareCredit no interest payment plan.

        (215) 357-1180