Mark A. Skidmore, DDS-Patient Information

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Patient Information

Mark A. Skidmore, DDS

3059 Forest Hill Irene Road,
Germantown, TN 38138
(901) 754-2223

First Name*

Last Name*

Middle Name

City*

State*

Zip*

Date Of Birth*

Address*

Gender*

Marital Status*

Social Security Number*

Driving License Number

Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Extension Number

Would you like to receive a text message from us to remind you of your appoinment?

Email
Text Message
Both

Address*

City*

State*

Zip*

Home Phone Number

Cell Phone Number

Work Phone Number

Work Extension Number

Social Security Number

Driving License Number

Relation To Patient

Name Of Insured

Insured SSN

EmployerName

Insured Person's Address

DOB of Insured

Group Number

REM. BENEFITS

REM. DEDUCT

Insurance Company

Insurance Company Address

Insurance Company City

Insurance Company State

Insurance Company ZipCode

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 h

Are you under a physician's care now?

If Yes,

Have you ever been hospitalized or had a major operation?

If Yes,

Have you ever had a serious head or neck injury?

If Yes,

Are you taking any medications, pills or drugs?

If Yes,

Do you take, or have you taken,phen-fen or Redux

If Yes,

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

If Yes,

Are you on a special diet?

Do you use tobacco?

Do you use controlled substances?

If Yes,

Women, are you?

Pregnant/trying to get pregnant?
Nursing?
Taking oral contraceptives?

If Yes,

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

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valves

Artificial Joints

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Cold sores / Fever blisters

Congenital heart disorder

Convulsion

Cortisone medicine

Diabetes

Difficulty Breathing

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting spells / Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

Hay Fever

Heart Attack / Failure

Heart Murmer

Heart Pacemaker

Heart Trouble / Disease

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problem

Leukemia

Liver Disease

Low Blood Pressure

Lung diseases

Mitral Value prolapse

Osteoporosis

Pain in Jaw Joints

Parathyroid Disease

Psychiatric Care

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach/Intestinal Disease

Stroke

Swelling of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Yellow Jaundice

Have you ever had any serious illness not listed above?

If Yes

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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Our desire is to provide you with the highest quality service and exceptional dental care in a caring and enjoyable atmosphere. We value your time and strive to maintain your appointment at the allotted time, in return, we request the same from you. We will need at least 24 HOURS notice to cancel or reschedule an appointment.

Unfortunately, as a result of the significant increase in short notice cancellations and disregard for appointment confirmations, it has become necessary for us to enforce the following policy.

Failure to provide adequate notice may result in the following:

If you are more than5-7 minutes late for your appointment, it may be necessary for you to be reschedule and that appointment could be considered a cancellation without adequate notice. PLEASE call if you feel you may arrive later than your scheduled appointment time so that our team can make accommodations to see you.

a $25.00 fee MAY be accessed to your account and must be paid before being rescheduled.

Single patient scheduling, only one family member scheduled at a time, If multiple appointments are failed within the same day.

As a last resort and after MANY failed attempts to schedule appointments, we may have no choice but to dismiss your care from the practice.

**Thank you for your understanding that we are committed to being available to ALL our patients who need dental care.

** I HAVE READ AND UNDERSTAND THE POLICIES ABOVE:

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Your Privacy Is Important to Us

Acknowledgement of Receipt of Notice of Privacy Policies

I have received a copy of the Notice of Privacy Practices of M Skidmore D.D.S. I hereby authorize, as indicated by my signature below, to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form.

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Zip

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Patient Details( * mandatory to fill )

Contact Information( * mandatory to fill )

Responsible Party's Information( * mandatory to fill )

Emergency Contact Information( * mandatory to fill )

Primary Insurance Details( * mandatory to fill )

Medical History( * mandatory to fill )

Cancellation Policy( * mandatory to fill )

Receipt of Notice of Privacy Policies( * mandatory to fill )