Welcome Form

Patient Information

Thank you for trusting us with your dental care! We promise to do our best to provide you with the finest care available. Please fill out this form completely. The better we communicate, the better we can care for you.
Patient Name

First NameLast Name
Male / Female

MaleFemale
Date of Birth

MonthDayYear
Date
SSN:
Phone Number

Area CodePhone Number
Email Address:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Way of Contact to Confirm Appointment

Text MessageCall ReminderTime of PreferenceOther
Parent/Legal Guardian Information

(Only if patient under 18 years of age)
Parent/Legal Guardian Name:

First NameLast Name
Birth Date:

MonthDayYear
Date
Phone Number

Area CodePhone Number
Relation to patient
Insurance Information

If you have insurance, please complete the following information:
Insurance company
Primary insured’s name
Primary insured’s SSN or ID#
Birth Date

MonthDayYear
Date
Emergency Contact Information

In case of an emergency, please list the best person to contact:
Name

First NameLast Name
Phone Number

Area CodePhone Number
Referral Source

We love new patients & would like to know how you heard about us! Please check all that apply
Type a question

GoogleWebsiteMarketingTeamEventFriend/Family MemberDriveByFacebookInstagram
If any of the above please explain
Medical History
Do you have, or have had, any of the following? Please check all that apply

AIDS/HIVAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingFainting Spells/DizzinessFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucoma1-lay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/ DiseaseHemophiliaHepatitis A, B or CHerpesHIO Blood PressureHigh CholesterolHives or RashHypoglycemiaKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach DiseaseIntestinal DiseaseStrokeThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersYellow JaundiceOther Illness
If any of the above please explain
WOMEN: Are you
Pregnant/Trying to get pregnant?

YesNo
Taking oral contraceptives?

YesNo
Are you allergic to any of the following? Please check all that apply:

AspirinPenicillinAcrylicLatexCodeineLocal AnestheticsMetalSulfa DrugsOthers
If any of the above please explain
Are you under a physician’s care now? Yes or No
If yes, please explain:
Are you currently taking any medications, pills or drugs? Yes or No
If yes, please list:
Is anything bothering you today?
Preferred pharmacy name & location:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
Patient or Parent/Legal Guardian Signature

Clear
Today’s Date

MonthDayYear
Date
Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT AND REVIEW IT CAREFULLY!
By law we are required to provide you with our Notice of Privacy Practices (NNP). This notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.
As a patient, you have the following rights:
- The right to inspect a copy of your information;
- The right to request corrections to your information;
- The right to request your information () restricted;
- The right to request confidential communications;
- The right to a report of disclosure of your information; and
- The right to a paper copy of this notice.
We want to assure you that your medical protected health information is secure with us. This Notice of Privacy Practices contains information about how we ensure that your information remains private.

The following persons are authorized to have access to billing, appointment, and treatment information.
Nameblanks . Relation: blank
Nameblanks . Relation: blank
Acknowledgement of Notice of Privacy Practices

I hereby acknowledge that I have reviewed this practice’s Notice of Privacy Practices. I further understand that the practice will offer me updates to this notice. Should it be modified or changed in any way I will receive a copy.
Name of Patient

First NameLast Name
Signature of Patient or Parent/Legal Guardian

Clear
Today’s Date

MonthDayYear
Date
Should be Empty:

Patient Information

Notice of Privacy Practices