CONFIDENTIAL PATIENT INFORMATION

CONFIDENTIAL PATIENT INFORMATION
Patient Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Date
Social Security Number
Nickname
Guardian / Parent Name (If Patient is a Minor)

First NameLast Name
Name and age of other siblings or children
School
Grade
Whom may we thank for referring you to our office?
CONFIDENTIAL RESPONSIBLE PARTY INFORMATION
Name

First NameLast Name
Marital Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
OwnRent
Previous Address (If less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Social Security Number
Birthdate

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
Years Employed
Spouse’s Name

First NameMiddle NameLast Name
Spouse's Social Security Number
Birthdate

MonthDayYear
Date
Relationship To Patient
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Occupation
Years Employed
INSURANCE INFORMATION
Policy Holder’s Name

First NameMiddle NameLast Name
Social Security Number
Policy Holder Birthdate

MonthDayYear
Date
Insurance Company
ID / Group #
Insurance Phone # and Address
EMERGENCY INFORMATION
Name of nearest relative not living with you
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact #
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
I understand that where appropriate, credit reports may be obtained. I authorize Michael A. Beim, D.D.S., P.A. To release any information to my insurance company. I hearby authorize my insurance company to send payment directly to Michael A. Beim, D.D.S., P.A.
Signature (Parent's signature if patient is a minor)
MEDICAL AND HEALTH HISTORY INFORMATION
Patient’s Dentist
Date of last dental visit

MonthDayYear
Date
YesNo
What concerns you most about your teeth? *
Has an Orthodontist been previously consulted?*
Are antibiotics needed for a teeth cleaning?*
Any dental work that needs to be completed prior to beginning treatment? *
Patient’s Physician
Date Of Last Physical Exam

MonthDayYear
Date
Is the patient under the care of a Physician at this time? Please explain:
Do you play a musical mouth instrument?*
Are you aware that some appointments may be during school or work hours? *
List any medications being taken at this time: *
List any drug/ miscellaneous allergies:*
Please explain any medical/ dental problems or surgeries you have had:*
Do you have any disease, medical, or dental condition not listed below that you feel we should be aware of?*
Abnormal BleedingKidney DiseaseLiver DiseaseHeart ProblemsDiabetesSinus ProblemsPregnant NowHeart Murmur/MVPLatex AllergyPainful JointsPlastic/Metal AllergyFinger/Thumb SuckingLip/Tongue BitingClenching or GrindingJaw Clicking or PoppingSmoke/Chew TobaccoEpilepsy/Convulsions/SeizuresBone DisordersCancer or TumorHemophilia/Prolonged BleedingBruise or Bleed EasilyTuberculosis/Positive PPDAsthma or Hay FeverAlcoholism/Drug AddictionFrequent Colds/Sore ThroatAnemiaEar InfectionsMouth BreathingMissing Permanent TeethTonsils/Adenoid ProblemsDental PainHeadachesThyroid ProblemsAIDS/HIV PositiveFainting or DIzzinessHigh Blood PressureHepatitisSexually Transmitted DiseaseArthritisCold Sores/HerpesNervous DisordersDisabilitiesImplantsTooth/Jaw TraumaTongue ThrustSpeech ProblemsCavities NowExtra TeethNone
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office immediately of any changes in medical status.
Signature (Parent's signature if patient is a minor)
Date

MonthDayYear
Date
Should be Empty:

CONFIDENTIAL PATIENT INFORMATION

CONFIDENTIAL RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

EMERGENCY INFORMATION

MEDICAL AND HEALTH HISTORY INFORMATION