Patient Information
Marital Status
Dental Insurance - Primary
Is patient covered by additional insurance?
Dental Insurance - Secondary
Is patient covered by additional insurance?
Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with
. I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Edward P. Laco all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

Medical History

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 have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you use controlled substances?
Women: Are you
Are you allergic to any of the following?
Do you have or have you had any of the following?
Have you had any serious illness not listed above?
*Condition may require medication

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.

Dental History
Your current dental health is
Do you require antibiotics before dental treatment?
Are you currently in pain?
Have you ever had periodontal treatment?
Do you now or have you had any pain/discomfort in your jaw? (TMJ)
Have you ever had any injuries to your head or neck?
Are your teeth sensitive to cold or anything else?
Have you lost any teeth?
Are you wearing any dentures or partials?
Have you ever had any serious/difficult problems with any previous dental work?
Are you happy with the way your teeth look?
Are you happy with the way your teeth feel?
Is there anything you would like to change about your smile?

Dr. Laco offers a wide variety of services to enhance and keep your smile beautiful. Please check any services below that you would like our friendly staff to discuss with you during your visit:

Acknowledgement of receipt of statement of privacy practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Edward P. Laco, DDS, PC. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Edward P. Laco, DDS, PC reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

Additional Disclosure Authorization

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to each individual question, protected health information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse Only
Any member of my immediate family: (i.e. Spouse, Children, Siblings, etc.)
Any member of my extended family: (i.e. Parents, Grandchildren)
Office use only below this line
Acknowledgement Not Obtained
Provided Prior to Treatment?
Reason for not obtaining patient signature