Patient Information
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Sex
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Primary phone #
*
Please enter a valid phone number.
Secondary phone #
Please enter a valid phone number.
Emergency phone #
Please enter a valid phone number.
Do you currently see a General Dentist?
*
Please Select
Yes
No
Dentist name
When was your last visit?
-
Month
-
Day
Year
Date
How did you find out about us?
Please Select
Internet
TV
Dentist
Friend
Other
What is your main concern with your teeth
Responsible Party Information
Responsible Party
*
Please Select
Self
Parent
Spouse
Name
*
First Name
Last Name
Relationship(to patient
*
Sex
*
Please Select
Male
Female
Primary Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Dental Insurance Information
Do you have dental insurance?
Please Select
Yes
No
Policy Holder's Name
*
DOB
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company
*
Insurance Phone #
Please enter a valid phone number.
Employer
*
Social Security # or ID #
*
Patient History
Are you in good health?
*
Please Select
Yes
No
Has there been any change in your general health in the past year?
*
Please Select
Yes
No
Date of last physical exam?
*
-
Month
-
Day
Year
Date
Are you now under a physician’s care?
*
Please Select
Yes
No
Example
*
Have you ever had any serious illnesses,Operations of hospitalizations? If so, describe
DO YOU HAVE OR HAVE EVER HAD
*
A. Rheumatic Fever or Heart Disease?
B. Congenital Heart Disease?
C. Cardiovascular Disease (Heart Attack,Heart Trouble, Heart Murmur, Coronary Artery Disease, Angina, High Blood Pressure, Stroke,Palpitations, Heart Surgery, Pacemakers)?
D. Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis,Shortness of Breath, Chest Pain, Sever Coughing)?E. Seizures, convulsions, Epilepsy, Fainting or Dizziness?
F. Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion?
G. Liver Disease (Jaundice, Hepatitis)?
H. Kidney Disease?
I. Diabetes?
J. Thyroid Disease?
K. Arthritis?
N. Implants placed anywhere in your body (Heart valve, Pacemaker, Hip or Knee)?
O. Radiation (x-ray) treatment for cancer? P. Sinus or Nasal Problems?
Q. Any disease, drug or transplant operation that has depressed your immune system?
None
ARE YOU USING ANY OF THE FOLLOWING?
*
A. Antibiotics?
B. Anticoagulants (Blood Thinners)?
C. Aspirin or Ibuprofen?
D. High Blood Pressure medications?
E. Steroids?
F. Tranquilizers?
G. Insulin or Oral Anti-Diabetic Drugs?
H. Digitalis, Inderal, Nitroglycerin or otherheart Drugs?
I. Are you taking or have you ever taken Bisphosphonates (Fosamax, Actonel, Zometa,Bondronat, Aredia, Didronel, Bonefos, Loron, Skelid, Neridonate, Olparonate) for osteoporosis?
None
Please list any and all medications taken, Including prescription medications, over-the-Counter medications, herbal or holistic remedies, Vitamins or minerals.
ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION TO:
*
Local Anesthesia (Novocain, etc.)?
Penicillin or other antibiotics?
Sedatives or Barbiturates?
Aspirin or Ibuprofen?
Latex or Rubber Products?
Other allergies or reactions? Please list.
None
Allergies or reactions (please describe)
Do you smoke, chew tobacco or vape?
*
Please Select
Yes
No
How much per day?
# of years
Any past history of Alcohol or Chemical Dependency or Emotional Disorder?
*
Please Select
Yes
No
Have you had any serious problems associated with any previous dental treatment?
*
Please Select
Yes
No
Have you or an immediate family‘member had any problem associated with General Anesthesia?
*
Please Select
Yes
No
Do you have any other disease,condition or problem not listed above that you think the Doctor should know about?
*
Please Select
Yes
No
FOR WOMEN ONLY:
Is there a chance you could be pregnant?
Are you nursing?
Extra information
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