Confidential Information Questionnaire

Patient Information

Marital Status

Emergency Contact Information

Person we may contact in case of an emergency
(other than your family home)

Request for Confidential Communication

As my Dental Care Provider, you may do the following with my permission

Contact me at home
Contact me via cell phone
Contact me at work
Contact me via e-mail
Leave messages on my home voicemail
Leave messages on my cell phone voicemail
Leave messages on my work voicemail

Insurance and Financial Information

Insurance Coverage
Patient's Relationship to Subscriber
Secondary Coverage
Patient's Relationship to Subscriber

Release Information

You may discuss my healthcare with

Health Care Providers
Insurance Companies


Do you prefer a confirmation call?

Assignment & Release

I hereby authorize (1) any available insurance benefits to be paid directly to my dentist, (2) the release of my dental health care information for any of my dental health care insurance claim, (3) the use of my dental records by my dentist in any professional manner that he/she determines, (4) the making of videotapes, photographs, and x-rays of my dental care treatment (collectively “My Images”), and (5) my dentist’s use of My Images in scientific papers, demonstrations and/or presentations without compensation to me. I agree that to the extent the cost of the dental care provided by my dentist is not covered by insurance, I am obligated to pay him/her such uninsured cost (the “Uninsured Costs”) in accordance with his/her payment terms and policies. Finally, I certify that I have read or had read to me the contents of this form and understand the risks and limitations involved with the dental treatment that I am to receive.

If the above named Patient is a minor or unable to pay the his/her Uninsured Costs, the undersigned agrees to guaranty the payment of such Uninsured Costs to the Patient’s dentist in accordance with his/her payment terms and policies.

Medical History

What is your estimate of your general health?


Hospitalization for illness or injury
An allergic or bad reaction to any of the following:
Heart problems, cardiac stent within the last six months
History of infective endocarditis
Artificial heart valve, repaired heart defect (PFO)
Pacemaker or implantable defibrillator
Orthopedic or soft tissue implants (e.g. joint replacement, breast implant)
Heart murmur, rheumatic or scarlet fever
High or low blood pressure
A stroke (taking blood thinners)
Anemia or other blood disorder
Prolonged bleeding do to a slight cut (or INR > 3.5)
Pneumonia, emphysema, shortness of breath, sarcoidosis
Chronic ear infections, tuberculosis, measles, chicken pox
Breathing problems (e.g. asthma, stuffy nose, sinus congestion)
Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
Kidney disease
Liver disease or jaundice
Vertigo (e.g. "the room is spinning")
Thyroid, parathyroid disease, or calcium deficiency
Hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)
High cholesterol or taking statin drugs
Stomach or duodenal ulcer
Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
Osteoporosis / osteopenia or even taken anti-resorptive medications (e.g. bisphosphonates)
Arthritis or gout
Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
Contact lenses
Head or neck injuries
Epilepsy, convulsions (seizures)
Neurologic disorders (ADD/ADHD, prion disease)
Viral infections and cold sores
Any lumps or swelling in the mouth
Hives, skin, rash, hay fever
Tumor, abnormal growth
Radiation therapy
Chemotherapy, immunosuppressive medication
Emotional difficulties
Psychiatric treatment or antidepressant medications
Concentration problems or ADD / ADHD diagnosis
Alcohol / recreational drug use


Presently being treated for any other illness
Aware of a change in your health in the last 24 hours (e.g. fever, chills, new cough, or diarrhea)
Taking medication for weight management
Taking dietary supplements
Often exhausted or fatigued
Experiencing frequent headaches or chronic pain
A smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis)
Considered a touchy / sensitive person
Often unhappy or depressed
Taking birth control pills
currently pregnant
Diagnosed with a prostate disorder

List all medications, supplements, and or vitamins taken within the last two years


Dental History

How would you rate the condition of your mouth?
I routinely see my dentist every

Personal History

Please answer Yes or No to the following:

Are you fearful of dental treatment?
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

Gum and Bone

Please answer Yes or No to the following:

Do your gums bleed sometimes or are they ever painful when brushing or flossing?
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession, or can you see more of the roots of your teeth?
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
Have you experienced a burning or painful sensation in your mouth not related to your teeth?

Tooth Structure

Please answer Yes or No to the following:

Have you had any cavities within the past 3 years?
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Do you frequently get food caught between any teeth?

Bite and Jaw Joint

Please answer Yes or No to the following:

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
Are your teeth becoming more crooked, crowded, or overlapped?
Are your teeth developing spaces or becoming more loose?
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
Do you place your tongue between your teeth or close your teeth against your tongue?
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Do you clench or grind your teeth together in the daytime or make them sore?
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
Do you wear or have you ever worn a bite appliance?

Smile Characteristics

Please answer Yes or No to the following:

Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?

Billing Policy

  • You may receive a billing statement from Linty John-Varghese, Inc. once a month if a balance remains.
  • Complete and accurate insurance information is required at the I time of service in order to obtain authorization and to bill your insurance companies. If you do not have insurance, payment is due at the time of service unless special arrangements have been made prior to date of service with our billing office. If you discover you have insurance after treatment has been completed, it will not be processed for you.
  • Some insurance companies, such as Anthem, Superior, and United Health Care may send you the check. Therefore, full payment at the time of services is due.

Cancellation Charge Policy

There will be a $50 charge for no shows and appointments broken less than 24 hours in advance. Cancellations left on the answering machine when the office is closed the night prior is not considered 24 hours notice. This is for the consideration of other patients. Patients not showing or canceling less than 24 hours more than twice will be dismissed from the practice. A $80 charge will be assessed for broken crown appointments due to length of appointment time.

Returned Check Policy

There will a $35 charge for checks returned by the bank. (The bank charges us.)

Billing Statement Policy

  • We do the billing free of charge for you and submit it to your insurance company.
  • We accept most insurance plans.
  • Co-insurances, deductibles and co-payments are payable at the I time of service. The rest of the balance is payable after we have received payments from your insurance company.

Payment Methods

We accept cash, check, money order, MasterCard, Visa and Discover.

Our goal is to make your dental appointments as comfortable and as pleasant as possible. If you have any questions, suggestions or concerns, please feel free to discuss them with any of our office staff

I understand that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed.


Patient Consent Form

The Department of Health and Human Services has established a "Privacy Rule" to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients' consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient we want you to know that we respect the privacy of your personal dental records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal dental records. We may also have indirect treatment relationships with you (such as laboratories that only interact with doctors and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer.

You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

Compliance Assurance Notification for Our Patients

To Our Valued Patients:

The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) 1 with particular emphasis on the "Privacy Rule". We strive to achieve the very highest standards of ethics and integrity in performing services for our patients. I

It is our policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented J Compliance Program that we believe will help us prevent any inappropriate use of PHI.

We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any wr ay compromises our policy of integrity. More so, we welcome your input regarding any service problem o that we may remedy the situation promptly.

Thank you for being one of our highly valued patients.

The Epworth Sleepness Scale

How likely are you to doze off or fall asleep in the following situation, in contrast to feeling "just tired" ? This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you.

    0 = would never doze

    1 = slight chance of dozing

    2 = moderate chance of dozing

    3 = high change of dozing


Sitting and Reading

Watching T.V.

Sitting inactive in a public place (meeting, theatre)

As a passenger in a car for an hour without a break

Laying down to rest in the afternoon

Sitting and talking to someone

Sitting Quietly after lunch without alcohol

In a car, While stopped for a few minutes in traffic


Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.