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 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 Birthdate 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 Birthdate 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 Dr. James A. Diamond 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 JAMES A. DIAMOND, D.D.S. 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 either Judy or Lisa 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 Dr. Diamond 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 Please enter code above in the field below.