Androscoggin Dental Care - New Adult Patient Enrollment Form

New Patient Enrollment Form - Adults

Welcome To Our Family at Androscoggin Dental Care!
Patient Information
Full Name*

First NameMiddle NameLast Name
Nickname
If applicable
E-mail
Social Security #*
Date of Birth*

MonthDayYear
Sex*

MaleFemale
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell #
Home #:
Work #:
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
How Did You Hear About Us?*
Other family members seen by us:
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Primary Insurance Information
Do you have insurance?*

YesNo
Primary Insurance Carrier:*
Subscriber ID#:*
Group #:*
Insurance Mailing Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Phone Number*

Area CodePhone Number
Name of Insured:*

First NameLast Name
Employer Name:*
Insured's Birthdate:*

MonthDayYear
Date
Insured's Social Security #*
Do you have Secondary Insurance?*

YesNo
Secondary Insurance Information
Secondary Insurance Carrier:*
Secondary Subscriber ID#:*
Secondary Group #:*
Secondary Insurance Phone Number*

Area CodePhone Number
Secondary Insurance Mailing Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Employer Name:*
Name of Insured:*

First NameLast Name
Insured's Birthdate:*

MonthDayYear
Date
Insured's Social Security #*
Dental History
Are you currently experiencing any discomfort?*

YesNo
If Yes, Please Describe Your Pain or Discomfort*
Are you required to take antibiotics before a dental treatment?*

YesNo
Do your gums ever bleed?*

YesNo
Have you ever been told you have Periodontal Disease?*

YesNo
Please Rate Your Current Dental Health (choose one)*

GoodFairPoor
Do you Floss daily?*

YesNo
Do you Brush daily?*

YesNo
Which Type Of Bristles Do You Use?*

HardMediumSoft
Are your teeth sensitive to heat, cold or anything else?*

YesNo
When Was Your Last Dental Visit?*

Less Than 6 Months Ago6 to 12 Months Ago12 to 18 Months AgoMore Than 18 Months Ago
Are you happy with the way your smile looks?*

YesNo
If not, what would you change?*
Medical History
Primary Care Physician:
Primary Care Physician Phone Number:
Date Of Last Visit To Your Primary Care Physician

MonthDayYear
Date
Your current physical health is? (choose one)*

GoodFairPoor
Are you taking any prescriptions or over the counter medication?*

YesNo
If yes, please list it here*
Preferred Pharmacy Name:*
Preferred Pharmacy Location:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you smoke or use tobacco in any form?*

YesNo
If Yes, Please Describe Your Tobacco Use:*
Have you ever been told you snore or hold your breath while you sleep?*

YesNo
Have you ever taken Fosamax or any other Bisphosphonates?*

YesNo
Allergic to any of the following? (Select all that apply)*

No Known AllergiesAspirinBarbituratesCodeineDental AnestheticsErythromycinJewelry/MetalsLatexMintPenicillinSedativesSulfa DrugsNo AllergiesTetracyclineOther
What are your other allergies we should know about?*
Are you taking any of the following? (Select all that apply)*

NoAcetaminophenAntibioticsAntihistaminesBlood ThinnersBlood Pressure MedicationCold MedicationInsulin/Diabetes DrugsNitroglycerinSteroids/CortisoneRecreational DrugsThyroid MedicationTranquilizers
Have you had any of the following diseases or medical problems?*

NoAcid RefluxAlcohol AbuseAnemiaAnginaArtificial Bones/JointsArtificial ValvesAsthmaBlood TransfusionCancerChemo/RadiationColitis HeartCongenital Heart DefectDiabetesDrug AbuseEmphysemaEpilepsy/SeizuresGlaucomaHIV+/AIDSHeadachesHeart AttackHeart MurmurHeart Surgery/PacemakerHemophilia/Abnormal BleedingHepatitis Type AHepatitis Type BHepatitis Type CHepatitis Type DHepatitis Type EHerpes/Cold SoresHigh/Low Blood PressureKidney ProblemsLiver DiseaseLupusLyme DiseaseMitral Valve ProlapsePsychiatric TreatmentRheumatic FeverScarlet FeverShinglesSinus ProblemsStrokeThyroid ProblemsTonsillitisTuberculosisNo I have notUlcersVenereal DiseaseOther
What are the other diseases or medical problems we should know about?*
What was the date of your heart attack?*

MonthDayYear
Date
For Women Only:
Are you taking birth control pills?*

YesNo
Are You Nursing?*

YesNo
Are You Pregnant?*

YesNoUnsure
If Yes, How many weeks along are you?*
CONSENT
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Payment is due at time of service unless prior arrangements have been made. I understand that I am responsible for payment of services rendered as well as any copay and deductibles that my insurance does not cover.
Patient/Guardian (Type Name)*

First NameLast Name
Patient / Guardian Signature: (use mouse or finger to draw your signature)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Enrollment Form - Adults

Patient Information

Primary Insurance Information

Secondary Insurance Information

Dental History

Medical History

For Women Only:

CONSENT