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.
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
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Sex
*
Please Select
Male
Female
Marital Status
Please Select
Single
Married
Divorced
Widowed
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 Name
Last Name
Relationship to Patient
Address
Street, City, State Zip
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Occupation
Business/ Employer Address
Street, City, State Zip
Street Address Line 2
City
State / 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
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Sex
Please Select
Male
Female
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 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 Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
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?
HIV
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
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Are you taking birth control pills?
*
Yes
No
Dental History
Dental Complaint at this moment
Date of your last dental treatment
-
Month
-
Day
Year
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Date of your last cleaning
-
Month
-
Day
Year
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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
Do you smoke/vape or use tobacco products?
Yes
No
*
The above information is true and I will notify you of any changes.
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Submit
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