Business Hours


Monday – Thursday
8:00 a.m. – 5:00 p.m.

Friday
8:00 a.m. – 3:00 p.m.

Two Saturdays a month
9:00 a.m. – 1:00 p.m.

Sundays closed

Insurance Plans Accepted

 

Sidney D. Price DDS
117 Lazelle Road East, Suite D
Columbus OH. 43235

Phone: 614-888-3212
Toll Free: 1-888-870-3212
Fax: 614-888-3215
E-mail: babyprice@aol.com

 

 

Sidney D. Price DDS & Associates
Worthington Pediatric Dentists Inc.

Home               About Us               Photo Gallery               Forms/Referral               Contact Us & Map

Name:
Today's Date:
E-mail Address:
Bold = Required field
I prefer to be called:
Birthdate:
Gender:
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Age:
SS#:
Home Address:
Marital Status:
Single
Married
Divorced
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Hm #:
Pager / Cell #:
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DL #:
Employer:
Employer's Address:
How long there?
Occupation:
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Whom may we Thank for referring you?

Other family members seen by us:

Previous / Present Dentist:

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His / Her Name:

Employer:
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Birthdate:
Person Responsible for Account:
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Ext:
Hm #:
Billing Address:
Relation:
Employer:
DL #:
DL #:
Insured's Name:
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Insured's Birthday:
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Insurance Co. Name:

Insured's ID #:
Insured's Employer:
Insured's Employer:
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Insurance Co. Name:

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Insured's Birthday:
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Insured's Name:
Do you have a personal physician?
Yes
No
Physician's Name:
Phone #:
Last Visited Date:
Please Explain:

His / Her Name:

Relation:

Hm #:
Wk #:
Are you currently under the care of a physician?
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No
Your current physical health is:
Good
Fair
Poor
Do you smoke or use tobacco in any form?
Yes
No
Are you taking any prescription / over-the-counter or herbal supplement drugs?
Yes
No
Please list each one:
Have you ever taken Phen-Fen?
Yes
No
(Also known as Redux or Pondimin) If yes, when?
Week #:
For Woman: Are you using a prescribed method of birth control?
Yes
No
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Enemia
Yes
No
Arthritis
Yes
No
Artificial Bones/Joints/Valves
Yes
No
Asthma
Yes
No
Blood Transfusion
Yes
No
Cancer/Chemotherapy
Yes
No
Colitis
Yes
No
Congenital Heart Defect
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Emphysema
Yes
No
Fainting Spells
Yes
No
Frequent Headaches
Yes
No
Glaucoma
Yes
No
Epilepsy
Yes

No

Hay Fever
Yes
No
Heart Attack
Yes
No
Heart Murmur
Yes
No
Heart Surgery
Yes
No
Hemophilia
Yes
No
Hepatitis
Yes
No
HIV+/AIDS
Yes
No
Hospitalized for Any Reason
Yes
No
Kidney Problems
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lupus
Yes
No
Herpes/Fever Blisters
Yes
No
High Blood Pressure
Yes
No
Mitral Valve Prolapse
Yes
No
Pacemaker
Yes
No
Psychiatric Problems
Yes
No
Radiation Treatment
Yes
No
Rheumatic/Scarlet Fever
Yes
No
Seizures
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Problems
Yes
No
Stroke
Yes
No
Thyroid Problems
Yes
No
Tuberculosis (TB)
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Please list any medical condition(s) that you have ever had:
Aspirin
Yes
No
Codeine
Yes
No
Dental Anesthetics
Yes
No
Erythromycin
Yes
No
Jewelry / Metals
Yes
No
Latex
Yes
No
Penicillin
Yes
No
Tetracycline
Yes
No
Other
Yes
No
Please list any other drugs/materials that you are allergic to:
Why have you come to the dentist today?
Has your doctor told you that you require antibiotics before dental treatment?
Yes
No
Are you currently in pain?
Yes
No
Have you ever had a serious / difficult problem associated with any previous dental work?
Yes
No

Forms for First Visit


Please click on the links below to download the PDF forms. Print and fill these forms out prior to your first visit. Thank you. 

PDF Forms

Adult Form
 
Financial / Payment Insurance Information
 
Kids Form
 
Notice of Privacy Practices

 

Click to get Adobe Reader

 

 

Electronic Forms
Adult Form
 
Financial / Payment Insurance Information
 
Kids Form
 
Notice of Privacy Practices

Primary Dental Insurance

Second Dental Insurance

In the event of an emergency, is there someone who lives near you that we should contact?

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following?

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