• Form

  • Patient Information

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Marital Status
  • Format: (000) 000-0000.
  • Spouse's Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dental Insurance

  • Is patient covered by additional insurance?
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • I certify that I, and/or my dependent(s), have insurance coverage with      and assign directly to Dr.      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 authorize the use of my signature on all insurance submissions.

    The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Phone Numbers

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Dental History

  • Date of last dental visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last dental X-rays
     - -
    2 digit month, 2 digit day, 4 digit year
  • Place a mark "yes" or "no" to indicate if you have had any of the following
    Rows

  • Health History

  • Date of Last Visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.*
  • Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin (bran names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).*
  • Place a mark on "yes" or "no" to indicate if you have had any of the following:
    Rows

  • Women:
    Are you pregnant?      
    Due date   Pick a Date
    Are you nursing?      
    Taking birth control pills?      

  • Medications

  • Format: (000) 000-0000.

  • Allergies

  • Allergies

  • Updates

    (To be filled in at future appointments)
  • Has there been any change in your health since your last dental appointment?*
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: