Packard Family Dentistry New Patient Form

  • PATIENT REGISTRATION

  • Date of Birth*
     - -
  • Sex*
  • Marital Status*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • PERSON RESPONSIBLE FOR ACCOUNT

  • Who is responsible for the account?*

  • (Please fill in the following information if the person responsible is different from self.)

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

  • INSURANCE INFORMATION

  • Do you have dental insurance?*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Were you assisted in completing this form?*

  • If patient was assisted with this form, enter name of person assisting:

  • Date*
     - -

  • MEDICAL HISTORY

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry that you will be receiving. Thank you for answering the following questions. 

  • General Health (please check):*
  • Format: (000) 000-0000.
  • Date of Last Physical*
     - -
  • Are you now under the care of a physician?*
  • Are you pregnant or do you think you may be pregnant?*
  • Are you nursing?*
  • Are you taking birth control pills?*
  • Do you smoke?*
  • Are you taking medications now?*
  • Rows
  • Do you use tobacco?*
  • Have you ever taken Fen-Phen or Redux?*
  • Have you required a blood transfusion?*
  • Are you wearing contact lenses?*
  • Do you or have you used controlled substances?*
  • Do you bruise easily*
  • Rows
  • Rows
  • Rows
  • Date
     - -

  • DENTAL HEALTH AND APPEARANCE

  • Approximate date of last dental visit:*
     - -
  • Have you ever had any serious problem associated with previous dental treatment or any dental emergencies?*
  • Do you have missing teeth?*
  • If yes, have you had them replaced?*
  • If you have had missing teeth replaced, are you happy with the results?*
  • If not, would you like to learn about our options to replace them?*
  • Do you ever feel (or have you ever been told) that you don't have fresh breath?*
  • What type of brush do you use?*
  • Do you avoid brushing any part of your mouth because of pain?*
  • Which food causes you twinges of pain?*
  • Did you lose fillings or break fillings?*
  • Do you chew on only one side of your mouth?*
  • Do your gums feel tender or swollen?*
  • Do you usually have many cavities?*
  • Do you clench or grind your jaws while sleeping or during the day?*
  • Do your jaws ever feel tired?*
  • We respect your rights to choose the level of care that fits your needs. We've found that many adults are unaware that problems even exist. There are rarely symptoms (pain, bleeding) associated with the aging and deterioration of teeth and gums - until it is far too late. According to the ADA, more than 80% of adult Americans have some level of gum disease. With your permission we would like to explain the choices available to achieve long-term health and beauty for your existing natural teeth. Please check all that apply:*

  • COSMETIC/ESTHETIC EVALUATION

  • Would you like to have whiter teeth?*
  • If you had a magic wand, what, if anything, would you change about your smile? Please check off all apply:

  • Limited Patient Authorization for Disclosure of Protected Health Information

  • Date of Birth*
     - -

  • Entity requested to Release Information: Packard Family Dentistry

    Purpose of request (who will be authorized to receive information) - I authorize the entity listed above disclose or provide protected health information, about me to the individual listed below.

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

  • Secure Communication - Note that regular email is not secure, and it is possible for your PHI to be compromised during transmission from our practice. Do not designate email if this is a concern to you.

  • Description of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the person(s) identified above:*
  • Should be Empty: