• Patient Information

  • Date
     / /
  • Sex
  • Birthdate
     / /
  • Format: (000) 000-0000.
  • Birthdate
     / /

  • Dental Insurance

  • Is patient covered by additional insurance?
  • Birthdate
     / /

  • ASSIGNMENT AND RELEASE

  • I certify that I, and/or my dependent(s), have insurance coverage with

  • and assign directly to

  • all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

  • The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

  • Please print name of Patient, Parent, Guardian or Personal Representative

  • Date
     / /

  • Phone Numbers

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

  • IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household

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

  • Dental History

  • Date of last dental visit
     / /
  • Date of last dental X-rays
     - -

  • Place a mark on "yes" or "no" to indicate if you have had any of the following:

  • Bad Breath
  • Bleeding gums
  • Blisters on lips or mouth
  • Burning sensation on tongue
  • Chew on one side of mouth
  • Cigarette, pipe, or cigar smoking
  • Clicking or popping Jaw
  • Dry mouth
  • Fingernail biting
  • Food collection between the teeth
  • Foreign objects
  • Grinding teeth
  • Gums swollen or tender
  • Jaw pain or tiredness
  • Lip or cheek biting
  • Loose teeth or broken fillings
  • Mouth breathing
  • Mouth pain, brushing
  • Orthodontic treatment
  • Pain around ear
  • Periodontal treatment
  • Sensitivity to cold
  • Sensitivity to heat
  • Sensitivity to sweets
  • Sensitivity when biting
  • Sores or growths in your mouth

  • Dental Registration and History

     

  • Health History

  • Date of last visit
     / /
  • Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva
  • Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin brand names of phentermine, Pondimin fenfluramine and Redux dexfenfluramine

  • Place a mark on "yes" or "no" to indicate if you have had any of the following:

  • AIDS/HIV
  • Anemia
  • Arthritis, Rheumatism
  • Artificial heart valves
  • Artificial joints
  • Asthma
  • Back problems
  • Bleeding abnormally, with extractions or surgery
  • Blood Disease
  • Cancer
  • Chemical Dependency
  • Chemotherapy
  • Circulatory Problems
  • Congenital Heart Lesions
  • Cortisone Treatments
  • Cough, persistent or bloody
  • Diabetes
  • Emphysema
  • Do you wear contact lenses?
  • Epilepsy
  • Fainting or dizziness
  • Glaucoma
  • Headaches
  • Heart Murmur
  • Heart Problems
  • Hepatitis
  • Herpes
  • High blood pressure
  • Jaundice
  • Jaw Pain
  • Kidney Disease
  • Liver Disease
  • Low Blood Pressure
  • Mitral Valve Prolapse
  • Nervous Problems
  • Pacemaker
  • Psychiatric Care
  • Radiation Treatment
  • Respiratory Disease
  • Rheumatic fever
  • Scarlet Fever
  • Shortness of Breath
  • Sinus Trouble
  • Skin Rash
  • Special Diet
  • Stroke
  • Swollen Feet or Ankles
  • Swollen Neck Glands
  • Thyroid Problems
  • Tonsillitis
  • Tuberculosis
  • Tumor or growth on head or neck
  • Ulcer
  • Venereal Disease
  • Weight Loss, unexplained

  • Women:

  • Are you pregnant?
  • Due date
     / /
  • Are you nursing?Yes
  • Taking birth control pills?

  • Medications

  • Format: (000) 000-0000.

  • Allergies

  • Updates (To be filled in at future appointments)

  • Has there been any change in your health since your last dental appointment?
  • Date
     - -
  • Date
     / /
  • Has there been any change in your health since your last dental appointment?
  • Date
     / /
  • Date
     - -
  •  
  • Should be Empty: