Patient Information Ver. 2.3

Patients place of employment*

In case of emergency, whom should be notified?
(Please include phone number)*

Person responsible for your account
(If not yourself)

Whom may we thank for referring you?

Payment & Insurance Information

How will patient pay for procedure(s)?*

Insured Party Same As Patient?*

Is there a secondary insurer?

Secondary Party Insurance Information

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for thoroughly answering the following questions.

Are you under a physicians care now?*

Please Explain

Have you ever been hospitalized or had a major operation?*

Please Explain

Have you ever had a serious head or neck injury?*

Please Explain

Are you taking any medications, pills, drugs or controlled substances?*

Please Explain

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

Are you on a special diet?*

Please Explain

Do you use tobacco?*

Please Explain

Are you trying to get pregnant?*

Are you taking oral contraceptives?*

Are you nursing?*


Are you allergic to any of the following? (By leaving any of these fields blank, you are stating "No")

Do you have, or have you had any of the following? (By leaving any of these fields blank, you are stating "No")

Have you ever had any serious illness not listed above?*

Acknowledgement of Receipt of Notice of Privacy Practice

*** You May Refuse To Acknowledge This Section ***

I have received a copy of this offices Notice of Privacy Practices:*

Authorization And Financial Responsibility

I hereby authorize payments to Dr. Gregory M. Sweeney, Jr. of any insurance benefits available for payment on this account. I understand that Dr. Sweeney’s office will attempt to file on any available insurance but this office is not responsible for the processing and handling of any insurance claim nor is acting as my agent for processing and handling of any insurance claim. I am responsible for the entire account balance in the event that there is no insurance payment. Accounts that have not been paid in full within 30 days, unless other arrangements have been made, will be submitted to a collection agency. Failure to make payments as agreed upon is basis for legal action and the undersigned agrees to pay all reasonable attorney and collection agency fees (33.33%) and/or court cost. I hereby waive now and forever my rights of exemption under the laws of the U.S. Constitution of the State of Alabama and any state.

I have read and agree to these terms:

By entering your name in this field, you are effectively signing this document:*

First, Last

Receive Appointments Reminders Via E-Mail, Text Or Cell Phone

How would you like to receive appointment reminders?

Your e-mail address:

Cell Phone:

We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services for Dr. Gregory M. Sweeney, Jr. in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. These parties may use your email or any numbers associated with your account, to better provide adequate service with your account or to collect monies you may owe. Your PHI may be disclosed to an affiliate that performs services for Dr. Gregory M. Sweeney, Jr. in the administration of your benefits. Our affiliates to not sell, rent or share our users’ personally identifiable information unless required by law, do not send email or other communications without user permission, and do not send spam.

General Dentistry Informed Consent

Treatment Plan

I understand the recommended treatments and my financial responsibility as explained to me. I acknowledge that during treatment it may be necessary to change or add procedures due to conditions found while working on the teeth that were not discovered during examination (ie: endodontic therapy following routine restorative procedures). I understand that by signing this consent I am in no way obliged to any treatment.

Drug And Medications

I understand that antibiotics, analgesics, local anesthetics, and other medications used within the dental office can cause side effects and/or allergic reactions. Examples include, but are not limited to: redness, swelling, itching, pain, vomiting and/or anaphylactic shock.


I understand that a more extensive restorative procedure than originally diagnosed may be required due to additional or extensive decay, discovered at the time of treatment. I understand that significant sensitivity is a common after effect of newly placed fillings. I understand that care must be exercised in chewing on newly restored teeth, especially during the first 24 hours to avoid breakage.

Crowns, Bridges and Veneers

I understand that sometimes it is not possible to match the color of natural teeth with artificial teeth. I further understand that I will be wearing temporary crowns/bridges which come off easily or break, and care must be taken to ensure that they are kept on until the permanent crown is delivered. I realize the final opportunity to make changes (shape, fit, size and color) will be before permanent cementation. It is my responsibility to return for permanent cementation within 20 days from tooth preparation. Excessive delays may allow for tooth movement that may necessitate a remake of the crown or bridge. I understand that there will be additional charges for remakes due to my delaying permanent cementation or wanting to make cosmetic changes after permanent cementation.

Endodontic Therapy

I realize that there is no guarantee that root canal therapy will save my tooth. I understand that complications can occur from the treatment, and that occasionally root canal filling material may extend through the tooth which does not necessarily affect the success of the treatment. I understand that endodontic files and reamers are very fine instruments and stresses and defects in their manufacture can cause them to separate during use. I understand that occasionally additional surgical procedure may be necessary following root canal treatment (apicoectomy). I understand that the tooth may be lost in spite of all efforts the restore it.


Alternatives to removal of teeth have been explained to me (root canal therapy, crown and bridge procedures, periodontal therapy, etc…). I understand removing teeth does not always remove infection, if present, and it may be necessary to have additional treatment. I understand I may require further treatment by a specialist if complications arise during or following treatment for which the cost is my responsibility. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time, or fractured jaw.

Partials And Dentures

I understand the wearing of partials/dentures is difficult. Sore spots, altered speech, and difficulty eating are common problems. Immediate dentures (dentures placed immediately after extractions) may be painful during the healing process. Immediate dentures may also require considerable adjusting and several relines. A permanent reline will be needed at a later date, at an additional cost to me. I understand that it is my responsibility to return for delivery of my partial/denture and that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delays of more than 30 days, additional charges will be incurred.

Periodontal Disease

I understand that I have been diagnosed with a serious condition, causing gum and bone inflammation and/or loss and the result could lead to the loss of teeth. Alternative treatments have been explained to me, including gum surgery, tooth extraction and/or replacement. I understand that dentistry is not an exact science and, therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment, which I have requested and authorized.

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 patients) health. It is my responsibility to inform the dental office of any changes in medical status.

I certify that the information above is correct to the best of my knowledge:*

By entering your name in this field, you are effectively signing this document:*

First, Last


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