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954-530-5352
support@handsondental.co

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Dental Insurance We Accept

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New Patient Information

Welcome to Hands on Dental Team! We are looking forward to meeting you. Please fill out the forms below.

Medical History Form

Dental Insurance We Accept

New Patient Form

Our passion and commitment is to keep you smiling

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Sat 10am-3pm
Sun 10am-3pm

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2633 E Commercial Blvd Fort Lauderdale, FL 33308, USA
support@handsondental.co
954-530-5352

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Medical History

Please enable JavaScript in your browser to complete this form.

- Step 1 of 3

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Patient Name

Birth Date

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.

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Are you under a physician's care now?

Yes
No

If yes, please explain:

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Have you ever been hospitalized or had a major operation?

Yes
No

If yes, please explain:

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Have you ever had a serious head or neck injury ?

Yes
No

If yes, please explain :

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Are you taking any medications, pills, or drugs?

Yes
No

If yes, please explain :

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

Yes
No

If yes, please explain :

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

Yes
No

If yes, please explain :

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Are you on a special diet ?

Yes
No

Do you use tobacco ?

Yes
No

Do you use controlled substances?

Yes
No

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Women: Are you Pregnant/Trying to get pregnant?

Yes
No

Taking oral contraceptives?

Yes
No

Nursing?

Yes
No

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Are you allergic to any of the following ?

Aspirin
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa drugs
Other

If yes, please explain:

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

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AIDS/HIV Positive

Yes
No

Alzheimer's Disease

Yes
No

Anaphylaxis

Yes
No

Anemia

Yes
No

Angina

Yes
No

Arthritis/Gout

Yes
No

Artificial Heart Valve

Yes
No

Artificial Joint

Yes
No

Asthma

Yes
No

Blood Disease

Yes
No

Blood Transfusion

Yes
No

Breathing Problem

Yes
No

Bruise Easily

Yes
No

Cancer

Yes
No

Chemotherapy

Yes
No

Chest Pains

Yes
No

Cold Sores/Fever Blisters

Yes
No

Congenital Heart Disorder

Yes
No

Convulsions

Yes
No

Cortisone Medicine

Yes
No

Diabetes

Yes
No

Drug Addiction

Yes
No

Easily Winded

Yes
No

Emphysema

Yes
No

Epilepsy or Seizures

Yes
No

Excessive Bleeding

Yes
No

Excessive Thirst

Yes
No

Fainting Spells/Dizziness

Yes
No

Frequent Cough

Yes
No

Frequent Diarrhea

Yes
No

Frequent Headaches

Yes
No

Genital Herpes

Yes
No

Glaucoma

Yes
No

Hay Fever

Yes
No

Heart Attack/Failure

Yes
No

Heart Murmur

Yes
No

Heart Pacemaker

Yes
No

Heart Trouble/Disease

Yes
No

Hemophilia

Yes
No

Hepatitis A

Yes
No

Hepatitis B or C

Yes
No

Herpes

Yes
No

High Blood Pressure

Yes
No

High Cholesterol

Yes
No

Hives or Rash

Yes
No

Hypoglycemia

Yes
No

Irregular Heartbeat

Yes
No

Kidney Problems

Yes
No

Leukemia

Yes
No

Liver Disease

Yes
No

Low Blood Pressure

Yes
No

Lung Disease

Yes
No

Mitral Valve Prolapse

Yes
No

Osteoporosis

Yes
No

Pain in Jaw Joints

Yes
No

Parathyroid Disease

Yes
No

Psychiatric Care

Yes
No

Radiation Treatments

Yes
No

Recent Weight Loss

Yes
No

Renal Dialysis

Yes
No

Rheumatic Fever

Yes
No

Rheumatism

Yes
No

Scarlet Fever

Yes
No

Shingles

Yes
No

Sickle Cell Disease

Yes
No

Sinus Trouble

Yes
No

Spina Bifida

Yes
No

Stomach/Intestinal Disease

Yes
No

Stroke

Yes
No

Swelling of Limbs

Yes
No

Thyroid Disease

Yes
No

Tonsillitis

Yes
No

Tuberculosis

Yes
No

Tumors or Growths

Yes
No

Ulcers

Yes
No

Venereal Disease

Yes
No

Yellow Jaundice

Yes
No

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Have you ever had any serious illness not listed above?

Yes
No

Please explain answers.

Comments

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

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SIGNATURE OF PATIENT, PARENT, or GUARDIAN

DATE

Ameritas Life
Aetna Life Ins. Co.
Argus Dental & Vision Plan By AFCAC Barefit Solution
Careington Dental
Connection Dental Network
DentaQuest
DenteMax
Dentegra Dental
Delta Dental Ins. Co.
Florida Blue
Florida Combined Life
Florida Medicaid

GEHA
Guardian Dental Ins.
Humana Health Plan Of Florida
Lincoln Dental
Liberty Dental Plan
MCNA Dental
Medicare Florida
Met Life Dental
Premiere Dental Group
Principal Dental Ins.
United Concordia Dental
United Healthcare Ins.
Diverse Care – Sun Health and Dental Plan

Patient Registration

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Name: *

First

Middle

Last

Preferred Name: *

Patient Is:

Policy Holder
Responsible Party

Responsible Party (if someone other than the patient)

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Home Phone:

Work Phone:

EXT:

Cellular:

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Birth Date:

Soc Sec:

Drivers Lic:

Responsible Party is also a Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder

Patient Information

Address

Address Line 1

Address Line 2

City

State

Zip Code

Pager

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Home Phone:

Work Phone:

EXT:

Cellular:

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Sex:

Male
Female

Marital Status:

Married
Single
Divorced
Separated
Widowed

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Birth Date:

Age:

Soc. Sec:

Drivers Lic:

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Email *

I would like to receive correspondences via e-mail.

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Employment Status:

Full Time
Part Time
Retired

Student Status:

Full Time
Part Time

Additional Comments:

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Medicaid ID:

Employer ID:

Carrier ID:

Pref. Dentist

Pref. Pharmacy:

Pref. Hyg:

Primary Insurance Information

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Name of Insured:

Relationship to Insured:

Self
Spouse
Child
Other

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Insured Soc. Sec:

Insured Birth Date:

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Employer:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Rem. Benefits:

Ins. Company:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Rem. Deduct:

Secondary Insurance Information

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Name of Insured:

Relationship to Insured:

Self
Spouse
Child
Other

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Insured Soc. Sec:

Insured Birth Date:

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Employer:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Rem. Benefits:

Ins. Company:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Rem. Deduct:

Emergency Contact Information Form

Name *

First

Middle

Last

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Home Phone:

Cell:

Home Email Address: *

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Primary Emergency Contact Name: *

First

Last

Relationship:

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Phone Home:

Cell:

Work:

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Secondary Emergency Contact Name: *

First

Last

Relationship:

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Phone Home:

Cell:

Work:

Preferred Local Hospital:

Insurance Information:

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Company:

Policy #:

Comments (include any special medical or personal information you would want an emergency care provider to know – or special contact information:

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Signature

Date

Be Young Everyday With Our HandsOn-SkinCare Line

Be Young Everyday With Our HandsOn-SkinCare Line

Office Location - Fort Lauderdale