www.pineycreekdental.com - Patient Information Form

Patient Information
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Social Security Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Marital Status
If "Other" Please Explain
Gender
Date of Birth

MonthDayYear
How did you hear about Piney Creek Family Dentistry?
ReferralMailingNewspaper AdWebsitePhone BookBuilding SignInsurance CompanyOther
Referral
If "Other" Please Explain
Primary Dental Insurance
Subscriber Name
Relationship to Patient
Date of Birth

MonthDayYear
Social Security Number
ID Number
Address (If different from patient)

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber’s Employer
Insurance Company
Group Number
Do you have secondary dental insurance?

YesNo
Secondary Dental Insurance
Subscriber Name
Relationship to Patient
Date of Birth

MonthDayYear
Social Security Number
ID Number
Address (If different from patient)

Street Address

Street Address Line 2

CityState

Zip Code
Subscriber’s Employer
Insurance Company
Group Number
Assignment and Release
I certify that I, and / or my dependent(s) have insurance coverage with
And assign directly to Piney Creek Family Dentistry and its associates 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.

Piney Creek Family Dentistry and its associates may use my health care information and may disclose such information to the above-named company and their agents for the purpose of obtaining payment of services and determining insurance benefits of the benefits payable for related services.
Signature of Patient / Subscriber*

Clear
Print Name of Patient / Subscriber*

First NameLast Name
Date*

MonthDayYear
Date
Relationship to patient
Contact Information
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What’s the best phone number & time of day to reach you?
Emergency Contact Information
Name*
Phone Number (1)*
Please enter a valid phone number.
Phone Number (2)*
Please enter a valid phone number.
Former Dentist
City / State
Date of last dental visit

MonthDayYear
Date
Date of last dental x-rays

MonthDayYear
Date
How often do you floss?
How often do you brush?
Please check all that apply
Bad BreathBleeding GumsBlisters on lips or mouthBurning sensation on tongueChew on one side of mouthCigarette / pipe / cigar smokingClicking or popping jawDry mouthFingernail bitingFood collection between teethForeign objectsGrinding teethGums swollen or tenderJaw painJaw tirednessLip or cheek bitingLoose teeth / broken fillingsMouth breathingMouth pain, brushingOrthodontic treatmentPain around earPeriodontal treatmentSensitivity to coldSensitivity to heatSensitivity to sweetsSensitivity when bitingSores / growths in mouth
Health History
Physician’s Name
Date of last visit

MonthDayYear
Date
Have you ever taken any medications containing bisphosphonates? This includes brands such as Fosamax, Actonel, Didronel, Boniva, Aredia and Zometa.*

YesNo
Have your had Botox?*

YesNo
Have your ever had Dermal Fillers?*

YesNo
Do you snore?*

YesNo
Do you wear a CPAP?*

YesNo
Have you ever been diagnosed with obstructive sleep apnea?*

YesNo
Please answer "Yes" or "No" to the following
AIDS / HIV*

YesNo
Anemia*

YesNo
Arthritis, Rheumatism*

YesNo
Artificial Heart Valves*

YesNo
Date

MonthDayYear
Date
Artificial Joints / Joint?*

YesNo
When?*
Asthma*

YesNo
Back Problems*

YesNo
Bleeding abnormally, with*

YesNo
Extractions or surgery?*

YesNo
Blood Disease*

YesNo
Cancer*

YesNo
Chemical Dependency*

YesNo
Chemotherapy*

YesNo
Circulatory Problems*

YesNo
Congenital Heart Lesions*

YesNo
Cortisone Treatments*

YesNo
Cough, persistent / bloody*

YesNo
Diabetes*

YesNo
Dizziness*

YesNo
Emphysema*

YesNo
Epilepsy*

YesNo
Fainting*

YesNo
Glaucoma*

YesNo
Headaches*

YesNo
Heart Murmur*

YesNo
Heart Problems*

YesNo
Hepatitis*

YesNo
Type*
Herpes*

YesNo
High Blood Pressure*

YesNo
Jaundice*

YesNo
Jaw Pain*

YesNo
Kidney Disease*

YesNo
Liver Disease*

YesNo
Low Blood Pressure*

YesNo
Mitral Valve Prolapse*

YesNo
Nervous Problems*

YesNo
Pacemaker*

YesNo
Psychiatric Care*

YesNo
Radiation Treatment*

YesNo
Respiratory Disease*

YesNo
Rheumatic Fever*

YesNo
Scarlet Fever*

YesNo
Shortness of Breath*

YesNo
Sinus Trouble*

YesNo
Skin Rash*

YesNo
Special Diet*

YesNo
Stroke*

YesNo
Swollen Feed / Ankles*

YesNo
Swollen Neck / Glands*

YesNo
Thyroid Problems*

YesNo
Tonsillitis*

YesNo
Tuberculosis*

YesNo
Tumor or growth on head or neck*

YesNo
Ulcer*

YesNo
Venereal Disease*

YesNo
Weight loss / Gain*

YesNo
Do you wear contact lenses?*

YesNo
Are you taking birth control pills?*

YesNo
Are you pregnant?*

YesNo
Are you nursing?*

YesNo
Medications
List any medications you are currently taking and the Correlating diagnosis
Allergies
AspirinCodeineDental AnestheticsSulfaLatexMetalsTetracyclinePenicillinErythromycinOther
If "Other" Please Explain
Consent
The undersigned herby authorizes the Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that my dental insurance is contract between the insurance carrier and me and not between the instance carrier and the Doctor and that I am still fully responsible for all dental fees. These fees are due and payable at the time services are rendered unless prior financial arrangements have been made. I also assign all insurance benefits to Doctor. Any payments received by the Doctor from my insurance coverage will be credited to my account or refunded to me if I have paid the dental fees incurred. I further understand that a late charge may be added to any overdue balance. I understand that, where appropriate, credit reports may be obtained.
Patient Signature (Parent of child)*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Patient Information

How did you hear about Piney Creek Family Dentistry?

Primary Dental Insurance

Secondary Dental Insurance

Assignment and Release

Contact Information

Emergency Contact Information

Please check all that apply

Health History

Please answer "Yes" or "No" to the following

Medications

Allergies

Consent