www.martintaylordentistry.com - Acquaintance Form

Acquaintance Form
Patient Name*

First NameLast Name
Preferred to be called
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Employer
Occupation
Home Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Work/Business Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Sex*
Marital Status
How did you hear about our practice?
Emergency Contact
Emergency Contact Name*
Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Person responsible for payments of account
Name

First NameLast Name
Relationship to Patient
Address

Street, City, State Zip

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Business/ Employer Address

Street, City, State Zip

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Work/Business Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Ext.
Birth date

MonthDayYear
Sex
Social Security Number
Dental Insurance Information
Primary Insurance Company
Employer
Subscriber’s Name
Social Security Number
Group Number
Union or Local Number
Patient’s Relationship to Subscriber

SelfSpouseChild
Is the Patient student?

YesNo
Name of School
(If Patient is a student)
Do you have Secondary Insurance?*

YesNo
Secondary Insurance Company *
Employer *
Subscribers Name*
Social Security Number*
Group Number*
Union or Local Number*
Patient’s Relationship to Subscriber*

SelfSpouseChild
Authorization/Confirmation*

I authorize the release on any information necessary to process my insurance claim.I hereby authorize payment to the dentist of the insurance benefits otherwise payable to me. A copy of this signature if as valid as the original.
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
General Health History
Are you in good health?*

YesNo
If no, explain*
Are you under a physician care now?*

YesNo
If yes, explain *
Name of physician
Physician Address
Street, City, State Zip
Are you now taking any drugs or medication?*

YesNo
If yes, explain *
Are you sensitive or allergic to any drugs?*

YesNo
If yes, please list*
Have you been hospitalized in the past two years?*

YesNo
If yes, explain *
Do you now have or have you had any of the following?
HIVAllergiesAnemiaArtificial JointsAsthma or Hay FeverBisphosphonate/FosamaxBlood DiseasesCancerDiabetesEpilepsyFainting Spells or SeizuresHeart AttackHeart DiseaseHeart MurmurHerpesHepatitisHigh Blood PressureKidney DiseaseLatex AllergiesLiver DiseaseRheumatic FeverRheumatism or ArthritisStrokeStomach UlcersTuberculosisVenereal Disease
Do you have any disease, condition, or problems not listed?*

YesNo
What are they?*
For Women
Are you pregnant?*

YesNo
If yes, due date

MonthDayYear
Are you taking birth control pills?*

YesNo
Dental History
Dental Complaint at this moment
Date of your last dental treatment

MonthDayYear
Date of your last cleaning

MonthDayYear
Do you grind or clench your teeth?

YesNo
Pain in your jaw joint?

YesNo
Sore or Sensitive teeth?

YesNo
Do your gums bleed?

YesNo
Cold or Canker Sores

YesNo
Unpleasant taste?

YesNo
Do you smoke/vape or use tobacco products?

YesNo
*

The above information is true and I will notify you of any changes.
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

Acquaintance Form

Emergency Contact

Person responsible for payments of account

Dental Insurance Information

General Health History

Do you now have or have you had any of the following?

For Women

Dental History