www.martintaylordentistry.com - Acquaintance Form

Acquaintance Form
Patient Name *

First Name Last Name
Preferred to be called
Address *

Street Address

Street Address Line 2

City State / Province

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

Month Day Year
Sex *
Marital Status
How did you hear about our practice?
Emergency Contact
Emergency Contact Name *
Telephone Number *
Please enter a valid phone number.
Person responsible for payments of account
Name

First Name Last Name
Relationship to Patient
Address

Street, City, State Zip

Street Address Line 2
Employer
Occupation
Business/ Employer Address

Street, City, State Zip

Street Address Line 2
Home Telephone
Please enter a valid phone number.
Work/Business Telephone
Please enter a valid phone number.
Ext.
Birth date

Month Day Year
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

Self Spouse Child
Is the Patient student?

Yes No
Name of School
(If Patient is a student)
Do you have Secondary Insurance? *

Yes No
Secondary Insurance Company *
Employer *
Subscribers Name *
Social Security Number *
Group Number *
Union or Local Number *
Patient’s Relationship to Subscriber *

Self Spouse Child
Authorization/Confirmation *

I authorize the release on any information necessary to process my issuance 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 *

Clear
Name *

First Name Last Name
Date *

Month Day Year
General Health History
Are you in good health? *

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

Yes No
If yes, explain *
Name of physician
Physician Address
Street, City, State Zip
Are you now taking any drugs or medication? *

Yes No
If yes, explain *
Are you sensitive or allergic to any drugs? *

Yes No
If yes, please list *
Have you been hospitalized in the past two years? *

Yes No
If yes, explain *
Do you now have or have you had any of the following?
A.I.D.S Allergies Anemia Artificial Joints Asthma or Hay Fever Bisphosphonate/Fosamax Blood Diseases Cancer Diabetes Epilepsy Fainting Spells or Seizures Heart Attack Heart Disease Heart Murmur Herpes Hepatitis High Blood Pressure Kidney Disease Latex Allergies Liver Disease Rheumatic Fever Rheumatism or Arthritis Stroke Stomach Ulcers Tuberculosis Venereal Disease
Do you have any disease, condition, or problems not listed? *

Yes No
What are they? *
For Women
Are you pregnant? *

Yes No
If yes, due date

Month Day Year
Are you taking birth control pills? *

Yes No
Dental History
Dental Complaint at this moment
Date of your last dental treatment

Month Day Year
Date of your last cleaning

Month Day Year
Do you grind or clench your teeth?

Yes No
Pain in your jaw joint?

Yes No
Sore or Sensitive teeth?

Yes No
Do your gums bleed?

Yes No
Cold or Canker Sores

Yes No
Unpleasant taste?

Yes No
*

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

Clear
Name *

First Name Last Name
Date *

Month Day Year
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