NID New Patient Information

Welcome to New Image Dentistry. Please fill out our new patient form. The form is secure and we respect and value your information (see our Privacy Practices). We will do our best to make your appointments as convenient and pleasant as possible. If at any time you have any questions regarding your treatment, or fees, please feel free to ask. This confidential acquaintance form is important for our files and for your health. (941) 922-8769
Patient Name

First NameLast Name
Date

MonthDayYear
Social Security Number
E-mail
Daytime Phone Number

Area CodePhone Number
Business Phone

Area CodePhone Number
Fax Number

Area CodePhone Number
Marital Status
Place of Employment
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
If minor, name of Parent or Guardian and phone number
Birth Date

MonthDayYear
Sex
Age
Driver's License Number
Do You Have Dental Insurance?
Person Responsible for your Dental Care:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Relationship
Phone Number

Area CodePhone Number
Your payment will be made by
Dental Insurance Policy Holder
Policy Holder Social Security Number
Policy Holder Date Of Birth

MonthDayYear
Policy Holder Employer
Name of Your Physician
Why did you leave your last dentist?
Whom may we thank for referring you to us?
Have you been a patient in our office before?
Date of Last Dental Visit

MonthDayYear
Reason for your last visit?
Do you have Xrays or Dental Records?
Nearest Relative (not living with you)
Have you ever had any of the following (check yes or no):
Heart Trouble
Chest Pain
Heart Murmur
Pacemaker
Hypertension/Hi BP
Rheumatic Fever
___ Implant
Diabetes
Asthma
Lung Disease
Drug Allergy
Seizures
Blood Disease
Kidney Disease
Shortness of Breath
Liver Disease
Low Blood Pressure
Anemia
Epilepsy
Major Surgery
Hepatitis
AIDS Virus
Glaucoma
Thyroid Condition
Parkinsons Disease
If you were to change one thing about your smile, what would that be?
Are you currently in any dental pain?
Any part of your mouth sensitive to temperature or chewing?
Does food catch between your teeth?
Are you aware of your jaw clicking or popping when you chew or yawn?
If yes, explain
Do you have frequent headaches?
If yes, explain
Are you allergic to any of the following?
Are you under the care of a physician for any reason?
If yes, explain
Are you currently or have you recently been taking drugs or medications or vitamins & herbal supplements?
If yes, explain
Have you ever received Radiation Therapy (i.e. for tumors) of the face, head, neck or jaws?
If yes, explain
Do you have a problem with bleeding or clotting?
If yes, explain
Are there any other medical conditions of which we should be aware?
If yes, explain
When was your last physical exam

MonthDayYear
Was anything unusual or abnormal found?
If yes, explain
Female Patients: Are you taking birth control pills?
Are you or could you be pregnant?
If yes, Name and Phone Number of OB/GYN
Please be reminded that payment is due on the date on which services rendered. Other arrangements must be made in advance.
Do your gums bleed when you brush your teeth or toothpick between them?
Are your gums red, swollen, or tender?
Are your gums pulling away from your teeth?
Do you see pus between your teeth and your gums when your gums are pressed?
Are your permanent teeth loose or separating?
Is there any change in the way your teeth fit together when you bite?
Is there any change in the fit of your partial dentures?
Do you have bad breath?
Do you participate in contact sports that could potentially damage your teeth or oral tissues?
Do you wake up with headaches, dry mouth, or choking sensations?
Are you restless or perspire in your sleep?
Do you suffer fatigue or depression?
Do you experience difficulty concentrating or staying awake during the day?
Have you experienced frequent heartburn or rapid weight gain?
Does snoring disrupt your sleep or your significant other's sleep?
Please rate the following situations based on this sleepiness scale:

0 = would never doze; 1 = slight chance of dozing; 2 = moderate chance of dozing; 3 = high chance of dozing:
Sitting and reading
Watching television
Sitting, inactive in a public place (e.g. theater, meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstance permits
Sitting and talking to someone
In a car while stopped for a few minutes in traffic
Please review our Notice of Privacy Practices
I have read and agree to the Notice of Privacy Practices
By typing in your name and date below, you agree to the following: I've had full opportunity to read and consider the contents of this History, Consent and Notice of Privacy Practices. I understand that by submitting this form, I am giving consent to New Image Dentistry for the use and disclosure of my protected health information to carry out treatment, payment activities and health care operations, this represents my legal signature and agreement to the terms set forth in the Notice of Privacy Practices.
Full Name

First NameLast Name
Date

MonthDayYear
Should be Empty:

Person Responsible for your Dental Care:

Have you ever had any of the following (check yes or no):

Please be reminded that payment is due on the date on which services rendered. Other arrangements must be made in advance.