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8912 Blakeney Professional Dr #400, Charlotte, NC 28277
(704) 935-2700
Mon – Thurs 7am – 3pm
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Who may we thank for your referral?
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Dental History
Do you have any concerns you would like to address with Dr. Ghim at your first visit?
*
When was your last dental cleaning?
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Do your gums bleed when you brush and or floss?
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Yes
No
Have you ever had braces?
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Yes
No
Does food get caught between your teeth?
*
Yes
No
If yes, please explain where
*
Do you currently have any dental pain?
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Yes
No
If yes, please explain
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Are your teeth sensitive to hot, cold, or anything else?
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Yes
No
If yes, please explain
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Are you satisfied with the color of your teeth?
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Yes
No
Are you interested in professional teeth whitening?
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Yes
No
Do you have or ever had bad breath?
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Yes
No
Do you use any dental mouth rinses?
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Yes
No
If yes, please explain
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Do you use an electric toothbrush?
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Yes
No
Have you ever had a deep cleaning or have been numbed to get a cleaning?
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Yes
No
How often did you receive your cleanings?
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3 months
4 months
6 months
Other
If yes, please explain
*
Have you ever seen a gum specialist (periodontist) for the management of gum or bone disease?
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Yes
No
If yes, please explain
*
Do you smoke?
*
Yes
No
Do you use any other tobacco products?
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Yes
No
Are you happy with your smile?
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Yes
No
If no, please explain
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On a scale from 1-10, what would you rate your overall dental health?
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1
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10
Have you ever had any difficult / serious problem associated with previous dental work?
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Yes
No
If yes, please explain
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Have you ever been required to premedicate with antibiotics before dental appointments?
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Yes
No
If yes, please explain
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Have you ever had a negative dental experience?
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Yes
No
If yes, please explain
*
Medical History
Please take a moment to let us know about your medical and dental history so that we may serve you more effectively for your overall health and well-being.
Have you had any changes in your health, hospitalizations, or surgeries in the last 5 years?
*
Yes
No
If yes, please explain
*
Are you undergoing any care due to a specific condition?
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Yes
No
If yes, please explain
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Do you have any total joint replacements?
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Yes
No
If yes, please explain
*
Please check if you have or had any of the following. If NONE then please check those boxes
*
Select All
Acid Reflux
Anxiety/Nervousness
Asthma
Autoimmune disease
Allergies/Hay fever
ADD/ADHD
Arthritis/Gout
Autism
Anemia
Bleed Easily
Blood Transfusion
Birth Control pills
Bisphosphonate Use
Breathing Problems
Cancer
Cataracts
Chemotherapy
Colitis/Crohn's/IBS
Coumadin/Aspirin
Diabetes
Depression
Epilepsy/Seizures
Fainting/Dizziness
Fibromyalgia
Glaucoma
Headaches/Migraines
Hearing Impaired
Heart Attack/Surgery
Heart Murmur/MVP
Heart Problems-Other
Hepatitis
Herpes/Fever Blisters
High Blood Pressure
Hospitalization (any)
HIV / AIDS
High Cholesterol
Alc/Drug Abuse (w/in 6m)
Kidney Problems/Dis.
Liver Problems/Disease
Low Blood Pressure
Low Blood Sugar
Lupus
Multiple Sclerosis
Neck Pain/Head Injury
Nerve Pain
Pacemaker
Radiation Treatment
Rheumatic fever
Sickle Cell Dis/Trait
Sinus Problems
Stroke/TIA
Sleep Apnea
Thyroid Problems
Tuberculosis (TB)
TMJ Problems
Tumors
Ulcers
NONE
Are you taking any over the counter or prescription meds?
*
Yes
No
If yes, please list all
*
Allergies
*
Select All
Latex
Penicillin
Codeine
Aspirin
Other
NONE
Other
*
Your preferred pharmacy
CVS
Target
Walgreens
Harris Teeter
Rite Aid
Wal-Mart,
Pharmacy Phone Number
*
( XXX ) XXX-XXXX
Women
Are you Pregnant?
Yes
No
If yes, how many weeks pregnant
*
Nursing?
Yes
No
Primary Insurance
Insurance
*
I will not be using / or have any dental insurance.
I will be using my dental insurance.
Important Dental Insurance Information
We are pleased to inform our patients we accept insurance benefits from most dental carriers. As a courtesy to you we will file dental claims on your behalf and allow 30 days for your insurance policy to reimburse our office for treatment. Unpaid claims after 30 days for any reason will default to the patient’s responsibility. Any procedures not covered by insurance will require full payment at time of service. Please be mindful you are fully responsible for all fees associated with treatment provided regardless of your insurance decision to provide coverage. In the event that insurance has paid less than we had anticipated, you will receive a notification of any remaining balance which will be due upon receipt. Any overdue balances that are carried over may constitute a 15% re-occurring monthly interest fee.
Insured Name
*
First
Last
Insured's ID
*
Insurance company name
*
Insurance Company Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
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Nevada
New Hampshire
New Jersey
New Mexico
New York
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Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
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South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip/ Postal Code
Insurance Company Phone #
*
Name of Insured's Employer
*
Relationship to patient
*
Insured's Date of Birth
*
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Group #
*
Patient Agreement
We encourage any patient utilizing dental coverage to understand the limitations within your dental policy. We make every effort to provide the most accurate estimates for cost of treatment based on the information proved by your insurance company. Should questions arsie, it is best to contact your insurance company directly. While we estimate your dental benefits to the best of our ability, this is an ESTIMATE ONLY, and should not be depended on as a final decision. All applicable payment for services will be due at the time of scheduling.
Payments Options
For your convenience we accept payment in forms of cash, check, all major credit cards as well as no interest financing through CareCredit.
**CareCredit may be applied for prior to your appointment online at www.carecredit.com.
Any checks returned unpaid by your bank will be charged a $30.00 returned check fee and future payments will only be accepted in forms of cash or credit.
Copays and Estimates
We make every effort to provide the most accurate estimates for cost of treatment based on the information provided by your insurance company. All applicable payment for services will be collected at the time of your visit. While we will estimate your dental benefits to the best of our ability, this is an estimate ONLY, and should not be depended on as the final decision. Should questions arise, it is best to contact your insurance company directly. We encourage any patient utilizing dental coverage to understand the limitations within your dental policy.
Payment
*
I prefer to pay my copays at the time of scheduling
I prefer to pay for services in full at the time of scheduling and be reimbursed by my insurance carrier
Authorization for Release of Health Records to External Parties (optional)
I authorize the disclosure of information from my treatment records to:
Yes
Name of Recipient
Relationship to Patient
I give authorization to disclose the following information
All Treatment information
Information specifically related to these treatment dates
Starting Date
End Date
Appointments
We will always respect your time, and our team will make every effort to schedule appointments that accommodate the needs of all of our patients. In return, we ask that our patients make every effort to keep their reserved dental appointments.
As a courtesy you will receive verification of your appointment via text and email beginning 2 weeks prior to your appointment. We understand emergencies may arise and personal schedules may have unforeseen changes that prevent patients to keep their planned appointments. In the event you should need to reschedule an appointment, we ask for the consideration of a 48 hour notice. If an appointment is broken or an appointment is missed, it creates scheduling challenges for other patients as well as for our office.
** Repeated cancellations without adequate advanced notice will be subject to a non-refundable $50.00 broken appointment fee. For any further missed or broken appointments, our office reserves the right to dismiss a patient from the practice.
Privacy Policy
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