LAGUNA HILLS FAMILY DENTISTRY

Kristin Soraya DDS

23961 Calle de la Magdalena Suite #431 Laguna Hills, CA 92653
Welcome to Laguna Hills Dentistry Tell Us About
Yourself
Name:
_____________________Ralph______________Clayton_________________W______________
____________
Last First MI Title
Preferred Name: _________________________________________________________________ x Male Female
Address: 23431 Devonshire Dr City Lake Forest__ State __CA__
ZIP__92630___________
SSN: _570-77-9855_________________________ DOB: __11-17-
67_________________________________________
Home Phone: _________________________________ Work Phone:
_________________________________________
Cell Phone:_949-910-8659_________________________ E-mail Address:
_claytonwr@yahoo.com______________________
Employer:____________________________________ Occupation: _Customer Service
Rep_______________________
Marital Status: x Single Married Divorced Widowed Separated Domestic Partner
How did you hear about our office?__County of
Orange_________________________________________________________
Do you prefer to be contacted for appointment confirmation via e-mail or phone? (Please
circle preference)

Insurance Primary
Subscriber Name: _Clayton Ralph___________________ Relationship to Patient: _Self_______ Subscriber
DOB: _11-17-67_
Subscriber SSN/ID: ____________________________ Subscriber Employer:
____________________________________
Insurance Company Name: __Medi-
Cal______________________________________________________________________
Insurance Company
Address:___________________________________________________________________________
Insurance Company Phone: ______________________ Group Number:
_______________________________________

Insurance Secondary
Subscriber Name: _____________________________ Relationship to Patient: ___________ Subscriber DOB:
_________
Subscriber SSN/ID: ____________________________ Subscriber Employer:
____________________________________
Insurance Company Name:
____________________________________________________________________________
Insurance Company
Address:___________________________________________________________________________
Insurance Company Phone: ______________________ Group Number:
_______________________________________

Assignment and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to
Todays Dental 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.

Responsible Party Signature: __ Clayton

Ralph________________________________________________________
Relationship: _Self___________________________________ Date: __12-08-
17____________________________
CONSENT: I consent to the diagnostic procedures and treatment by the dentist necessary for proper
dental care.

Patient/Guardian
Signature:____________________________________________________________________________

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 LAGUNA HILLS FAMILY DENTISTRY
Kristin Soraya DD
23961 Calle de la Magdalena Suite #431 Laguna Hills, CA 92653
Medical History
Do you have a personal physician? Yes x No
Physicians
Name:___________________________________________________________________________________
_
Physicians Phone:
___________________________________________________________________________________
Date of last visit:
____________________________________________________________________________________
Your current physical health is: x Good Fair Poor
Are you currently under the care of a physician? Yes x No
Please explain:
______________________________________________________________________________________
Do you use tobacco in any form? Yes x No
Have you had any metal rods, pins or implants placed? Yes x No
Are you taking any medications? Yes x No
Please list each one:
__________________________________________________________________________________
Have you ever had any surgical procedures? Yes x No
Please list each one:
__________________________________________________________________________________
Yes No Conditions Yes No Conditions Yes No Conditions
x Abnormal Bleeding x Glaucoma x Sickle Cell Disease
x Alcohol Abuse x HIV+ AIDS x Sinus Problems
x Allergies x Heart Attack x Stroke
x Anemia x Heart Murmur x Thyroid Problems
x Angina Pectoris x Heart Surgery x Tuberculosis
x Arthritis x Hemophilia x Ulcers
x Artificial Heart Valve x Hepatitis A
x Asthma x Hepatitis B Yes No Allergies
x Blood Transfusion x Hepatitis C x Aspirin
x Cancer x High Blood Pressure x Codeine
x Chemotherapy x Joint Replacement x Dental Anesthetics
x Colitis x Kidney Problems x Erythromycin
x Congenital Heart Defect x Liver Disease x Jewelry
x Diabetes x Low Blood Pressure x Latex
x Difficulty Breathing x Mitral Valve Prolapse x Metals
x Drug Abuse x Pace Maker x Penicillin
x Emphysema x Psychiatric Problems x Tetracycline
x Epilepsy x Radiation Therapy
x Facial Surgery x Rheumatic Fever Yes No If Female, Please Answer
x Fainting Spells x Seizures Are you taking Birth
x Fever Blisters x Sexually Transmitted Disease Control Pills?
x Frequent Headaches x Shingles Are you pregnant?
If so, # of Weeks _______
Nearest relative not living with you: Are you nursing?
Name: __Wendy Ralph___________________ Relationship: _Parent____
Address: ____________________________________________________ Phone: __949-855-
3031____________
I understand that the information that I have given today is correct to the best of my knowledge. I also understand
that this infor-mation will be held in the strictest confidence and it is my responsibility to inform this office of any
changes in my medical status.

Signature: ____________________________________________________ Date: __12-08-

17___________________
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 LAGUNA HILLS FAMILY DENTIS
Kristin Soraya DDS
23961 Calle de la Magdalena Suite #431 Lagun
Dental History
How may we help you today? __2
Cavities____________________________________________________
Your current dental health is: Good x Fair Poor
Do you require antibiotics before dental treatment? Yes x No
Are you currently in pain? Yes x No
Have you ever had gum treatment? Yes x No
Do you now or have you had any pain/discomfort in your jaw joint? (TM
Are you under stress? (job, moving, relationships) x Yes No
Do you like your smile? Yes x No
Is there anything you would like to change about your smile? Yes
Are you happy with the color of your teeth? Yes x No
Do your gums bleed? Yes x No
How many times a do you: floss/week?_____0_____ brush/day?_____
Are your teeth sensitive to hot, cold or anything else? Yes x No
Have you lost any teeth? x Yes No
Have you ever had a serious/difficult problem with any previous dental wo
Have you ever had any unfavorable dental experiences? Yes x No
When was your last dental cleaning? __July 21
2017________________________________________________________
When was your last dental visit?
___Same_____________________________________________________
Why did you leave your previous dentist? __Dont accept Medi-
Cal____________________________________________
How can we accommodate you better during your dental
visit?_________________________________________________

Here at Todays Dental we offer a wide variety of services to enhance a

Please circle any services below you would like our friendly staff to disc

Traditional Orthodontics (Brackets) Smile Makeover

Sealants Crown and Bridge

Partials/Dentures Night/Sport Guards

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