• GENERAL HEALTH HISTORY
  • First Name
  • Last Name
  • Email
  • Are you in good health?
  • Yes No
  • If no, explain
  • Are you being treated by a physician now?
  • Yes No
  • Name of Physician
  • Phone
  • Are you now taking any drugs or medications?
  • Yes No
  • If yes, please list
  • Do you currently or have you ever taken any osteoporosis medications in the past?
  • Yes No
  • If yes, please list
  • Are you sensitive or allergic to any drugs?
  • Yes No
  • If yes, please list
  • Have you been hospitalized in the past two years?
  • Yes No
  • If yes, please explain
  • Do you now have or have you had any of the following?
  • Yes No
    A.I.D.S.
    Allergies
    Anemia or Blood Disease
    Asthma or Hay Fever
    Artificial Joint or Valve
    Cancer
    Diabetes
    Epilepsy
    Excessive Bleeding
    Fainting Spells or Seizures
    Heart Disease
    Heart Murmur
  • Yes No
    Herpes
    Hepatitis
    High Blood Pressure
    Kidney Disease
    Liver Disease
    Radiation Treatment
    Rheumatic Fever
    Rheumatism or Arthritis
    Stroke
    Stomach Ulcers
    Tuberculosis
    Venereal Disease
  • Do you have any disease or condition not listed above?
  • Yes No
  • if yes explain
  • Have you ever been told to pre-medicate with antibiotics before your dental treatment?
  • Yes No
  • WOMEN: Are you pregnant?
  • Yes No
  • If yes, due date
  • Are you taking birth control pills?
  • Yes No
  • Do you smoke, chew tobacco or vape?
  • Yes No
  • If yes how often
  • DENTAL HISTORY
  • What is the reason for your visit?
  • Date of your last dental treatment
  • Last Cleaning
  • How often do you brush your teeth?
  • Floss?
  • Do your gums bleed, or feel tender or irritated?
  • Yes No
  • Are your teeth sensitive to hot, cold, sweets or pressure?
  • Yes No
  • Are you aware of grinding or clenching your teeth?
  • Yes No
  • Do you have headaches, earaches or neck pains?
  • Yes No
  • Are you apprehensive about dental treatment?
  • Yes No
  • Have you ever had a bad reaction to dental anesthetic?
  • Yes No
  • Are you unhappy with the appearance of your teeth?
  • Yes No
  • Does food catch between your teeth?
  • Yes No
  • Have you ever worn braces on your teeth?
  • Yes No
  • Do you wear dentures?
  • Yes No
  • Are you unhappy with your dentures?
  • Yes No
  • Would you like us to help you learn the proper methods of home care, so you can stop dental problems before they start?
  • Yes No
  • The above information is true and I will notify you of any changes.
  • Signature
  • Date
  • ACQUAINTANCE FORM
  • I was referred to you by
  • Date
  • Name
  • I prefer to be called
  • Address
  • City
  • State
  • Zip
  • Home Telephone
  • Business Telephone
  • Other Telephone
  • E-Mail Address
  • Birth Date
  • Age
  • Sex
  • SS#
  • Marital Status
  • Spouse
  • Do you have any Children?
  • How Many?
  • Employer
  • Occupation
  • PERSON RESPONSIBLE FOR ACCOUNT
  • Name
  • Relationship to patient
  • Address
  • City
  • State
  • Zip
  • Home Telephone
  • Business Telephone
  • Birth Date
  • Sex
  • SS#
  • Employer
  • Occupation
  • DENTAL INSURANCE
  • Primary Insurance Company
  • Employee
  • SS#
  • Employer
  • Group Number
  • Secondary Insurance Company
  • Employee
  • SS#
  • Employer
  • Group Number
  • CONSENT: I authorize Armendariz Family Dentistry to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by him to make a diagnosis of my (my child's) dental needs. I understand that consultation with other health professionals may be required to assist with diagnosis of my (my child's) dental conditions. I authorize release of supporting records and information to and from this office for this purpose. I also understand that the use of anesthetic agents embodies a certain risk.
  • Signature of Patient, Parent or Guardian
  • Date
  • In case of emergency, please contact
  •  
  • Name
  • Telephone

Armendariz Family Dentistry
18555 N. 79TH AVE. SUITE B-104
GLENDALE, AZ 85308
(623) 334-2400

Financial Agreement-Please read the following information completely.

If you do not have dental insurance, the total fee is your responsibility. Payment is expected at the time of service. If you are unable to pay for services in full, please feel free to speak with Sherrie prior to having your treatment started to review payment options we have available. For your convenience, we accept cash, checks, VISA, Mastercard, Care Credit and American Express

As a courtesy to our patients with dental insurance, we are happy to assist in filing insurance claims for you. Please understand that dental benefits paid by your insurance carrier are determined by a contract between your employer and the insurance company and we can only provide an estimate of benefits. Any unpaid balance is your responsibility. We only provide composite (tooth-colored) fillings and some insurance companies may apply an alternate benefit for amalgam (silver) fillings. I authorize the release of any required information to my insurance company and authorize payment directly to Armendariz Family Dentistry for any claims submitted on my behalf

If you are unable to keep your appointment, we request at least TWO BUSINESS DAYS notice so we may give this time to another patient. Failure to do so may result in a missed appointment charge of $50.00. Please keep in mind, our days of business are Monday through Thursday.

I (we) agree to pay court costs, attorney fees and up to 50% of the collection fee on any outstanding balances that require placement with an outside agency.

  • Patient
  • Guardian
  • Date
dental dental dental
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