Triangle Family Dentistry

Patient Information

 
Please enter any updates to your address or contact information:
Appointment Location? *
Gender: *


Patient Medical History

Have you been seriously ill since your last office visit? *
Have there been any changes in your general health since you last office visit? *
Is A Medical Doctor Currently Treating You? *
Are you allergic to, or have you had unusual reactions to any of the following? (If none select 'No Known Allergies')
Have you had or been told you have any of the following?
Heart Defect................... *
Infective Endocarditis............. *
High Blood Pressure *
Herpes______________ *
Diabetes......... _____................ *
Low Blood Pressure *
Heart Attack................... *
Epilepsy..................................... *
Seizures *
Hives/Skin Rash............ *
Anemia.............>  > > > >.......... *
AIDS................ *
Arthritis.......................... *
Rheumatic Fever..........> > > .. *
Tuberculosis *
Hepatitis......................... *
Stroke.....................> > >......... *
Asthma *
Hay Fever....................... *
Kidney Disease . . . . . . . . .. . . *
Jaundice *
Venereal Disease..........  *
Pacemaker . . . . . . . . .  .  . .. .  *
Sinus Trouble *
Thyroid Problems . . . . . *
Active Infection . . . . . .  . . . .  *
Swollen Neck Glands *
Depression . . . . . . . .  . . *
Deviated Septum . . . . . . . . .  *
Osteoperosis *
Frequent Headaches . .  *
Cancer . .  . .  . .  . .  . .  . .  . .  . *
Other
Have you ever taken a bisphosphonate such as Fosamax, Actonel, or Boniva? *
Have you been told you snore occassionally? *
Do you wish you slept better and had more energy? *
Have you been prescribed or do you use a CPAP? *
Do you feel tired throughout the day? *

Women Only

Women who take oral contraceptives (birth control pills) should take extra precautions when taking antibiotics because antibiotics can cause failure of birth control pills which can result in pregnancy. 

Are you pregnant or suspect that you may be pregnant?
Are you taking oral contraceptives (birth control pills)?

CREDIT CARD ON FILE AGREEMENT

Triangle Family Dentistry is implementing a new credit card on file policy effective February 2023. Like many other dental and medical practices, we have adopted a similar policy. We kindly request our patient’s guardian/guarantor provide a credit card which will be used to pay a balance. Co-pays are still due at the time of service. Your credit card information will be obtained and kept securely on file.

After your claim is paid, we will process your card on file for any balances less than $100.00 and send you a receipt for the charge. For balances over $100.00, you will receive an electronic statement, and your prompt payment is expected within 7 days. You may call our office if you have questions about your balance.

This “Card-on-File” policy simplifies payment for you, and it reduces paperwork, ultimately helping lower the cost of care. Our Guest Support team is always available to answer questions about the Credit Card on File payment method or any balances due.

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By signing below, I authorize Triangle Family Dentistry to keep my signature and my credit card information securely on-file in my account. I authorize Triangle Family Dentistry to charge my credit card for any outstanding balances equal to or less than $100.00.
Credit Card Type:
*Please be advised, if the credit card on file differs from the CC info provided above, we will use the CC on file.*

Please list any person(s) you authorize this CC for:
Card Holder's Signature *
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Dental Questionnaire

My current dental goals are:
I have read and understand the above questions. I have answered all of these questions truthfully to the best of my ability and knowledge.
Signature *
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Thank you for taking the time to complete this form. 

We personalize your dental care based on the answers you’ve provided.