Patient Information
Date
-
Month
-
Day
Year
Date
Gender
Male
Female
N/A
Patient's Name
Last Name
First Name
Middle Name
Preferred Name
Family Status
Married
Single
Child
Other
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
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28
29
30
31
Day
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Social Security#
Email
example@example.com
Are you able to receive text message
Yes
No
Phone Number
Home
-
Area Code
Phone Number
Cell
-
Area Code
Phone Number
Work
-
Area Code
Phone Number
Work Ext
Address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Occupation
Employer
Whom may we thank for referring you to our office?
If not a patient then please list source of referral:
Contact in case of an emergency?
Name of Contact
Phone Number
-
Area Code
Phone Number
Responsible Party
(If different from above)
Patient's Name
Last Name
First Name
Middle Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State
Zip Code
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Social Security#
Relationship to Patient? (spouse, guardian, etc.)
Primary Dental Insurance Information
Insured’s Name:
Last Name
First Name
Middle Name
Insured’s Soc. Sec. #
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
ID #
Insurance Company:
Group #
Insurance Co. Address:
Insurance Co. Phone #
-
Area Code
Phone Number
Insured’s Employer:
Employer Phone #:
-
Area Code
Phone Number
Patient Dental and Medical History
Name of Previous Dentist and Location:
Date of Last Dental Visit:
-
Month
-
Day
Year
Date
How many times a week do you floss?
How many times a day do you brush?
Would you like your teeth whiter?
Do you like your smile?
Please select “Yes” or “No” to indicate if you have had any of the following:
Gums swollen or tender
Yes
No
Grinding your teeth
Yes
No
Lip or Cheek or Tongue biting
Yes
No
Sores/Growths in your mouth
Yes
No
Bad breath
Yes
No
Jaw Pain
Yes
No
Periodontal Treatment
Yes
No
Loose teeth or broken fillings
Yes
No
Bleeding gums
Yes
No
Sensitivity to sweets
Yes
No
Blisters on Lip or Mouth
Yes
No
Sensitivity to heat / cold
Yes
No
Clicking or popping jaw
Yes
No
Sensitivity when biting
Yes
No
Dry mouth
Yes
No
Burning sensation on tongue
Yes
No
Food collection between teeth
Yes
No
Trauma in mouth
Yes
No
Anxiety
Yes
No
Physician’s Name
Phone #:
-
Area Code
Phone Number
Last Visit Date:
-
Month
-
Day
Year
Date
Pharmacy Name:
Phone Number
-
Area Code
Phone Number
*Women:
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking Birth Control Pills?
Yes
No
Please select if you are allergic to or had any reactions to:
Ampicillin
Aspirin/Ibuprofen
Augmentin
Latex
Codeine
Sulfa
Percocet
Morphine
Local Anesthetic
Penicillin
Tetracycline
ANY Metals
Please list any other allergies you may have:
Are you taking blood thinners?
Yes
No
Baby Aspirin?
Yes
No
How often?
Do you need to take antibiotics prior to dental appointments?
Yes
No
Have you used bisphosphonate medications such as Actonel, Fosamax or Zometa within the past 12 years?
Yes
No
Are you currently taking any prescription or non-prescription medications (If yes, please list):
Please select “Yes” or “No” to indicate if you have had any of the following:
ADHD
Yes
No
Circulatory problems
Yes
No
Liver Disease
Yes
No
AIDS/HIV
Yes
No
Cortisone Treatments
Yes
No
Mitral Valve Prolapse
Yes
No
Allergies (seasonal)
Yes
No
Cough (persistent/bloody)
Yes
No
Nervous problems
Yes
No
Anemia
Yes
No
Diabetes
Yes
No
Pacemaker
Yes
No
Arthritis
Yes
No
Epilepsy
Yes
No
Psychiatric care
Yes
No
Artificial Heart Valves
Yes
No
Fainting or Dizziness
Yes
No
Radiation Treatments
Yes
No
Artificial Joints
Yes
No
Glaucoma
Yes
No
Respiratory problems
Yes
No
Asthma
Yes
No
Headaches
Yes
No
Scarlet Fever
Yes
No
Back Problems
Yes
No
Heart Murmur
Yes
No
Shortness of breath
Yes
No
Bleeding abnormally with extractions of surgery
Yes
No
Heart problems
Yes
No
Skin rash
Yes
No
Hemophilia
Yes
No
Stroke
Yes
No
Blood disease
Yes
No
Hepatitis
Yes
No
Thyroid problems
Yes
No
Cancer
Yes
No
Herpes
Yes
No
Tobacco habit
Yes
No
Chemical dependency
Yes
No
High Blood Pressure
Yes
No
Tuberculosis
Yes
No
Chemotherapy
Yes
No
Kidney Disease
Yes
No
Ulcers
Yes
No
Describe any conditions not listed above:
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including diagnosis and records of my treatment or examination rendered to me (or my child) during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist any insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services and agree to be responsible for payment of all services rendered on my behalf or my dependents. In the event that I seek credit from the dental office, I consent to release a copy of my credit report to the dental office.
Signature of Patient:
Signature of Doctor:
Submit Application
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