Hawkins and Rainwater New Patient Form

Name:*

First NameMiddle InitialLast Name
Preferred Name
Today's Date: *

MonthDayYear
Date
Gender:*
Family Status:*
Is anyone in your immediate family a current patient?*
If so, what is their name?
Social Security #:*
Date of Birth*

MonthDayYear
Phone (cell):*
Format: (000) 000-0000.
Phone (home):
Format: (000) 000-0000.
Phone (work):
Format: (000) 000-0000.
E-mail
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient or Parent/Guardian's Employer:
Work Phone:
Format: (000) 000-0000.
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse or Parent/Guardian's Name:
Spouse or Parent/Guardian's Employer:
If student, name of school or college:
Whom may we thank for referring you?
In case of emergency
Emergency Contact:

First NameLast Name
Relationship
Contact Number
Format: (000) 000-0000.
Name of Insured:
Relationship:
DOB of Insured:

MonthDayYear
Date
Insured's Social Security #:
Date Employed:
Name of Employer:
Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company:
Group #:
Policy ID #:
Insurance Company's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have additional insurance? If so, complete questions below.
Name of Insured:
Relationship:
Insured's DOB:

MonthDayYear
Date
Social Security #:
Date Employed:
Name of Employer:
Union/Local #:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company:
Group #:
Policy ID #:
Do you love your current smile?*
If not, what would you change about your current smile?
Have you ever had any of the following? Please check all that apply.*

Other
Are you pregnant?
If so, when is your due date?

MonthDayYear
Date
Are you taking oral contraceptives?
Physician:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Exam:

MonthDayYear
Date
Are you under medical treatment now?*
Have you ever been hospitalized for any surgical operations or serious illnesses within the last 5 years?*
Explain:
Please list all medications:
Have you ever taken any osteoporosis or cancer medications containing bisphosphonates (Fosamax, Boniva, Reclast, Actonel, etc)?*
If yes, please list the medication(s):
Do you use tobacco?*
Do you use controlled substances?*
Are you allergic to or have any reactions to the following?*

Other
Previous Dentist/Location:
Date of Last Dental Exam:

MonthDayYear
Date
Do your gums bleed while brushing?*
Are your teeth sensitive to hot/cold liquids, sweets, or foods?*
Do you feel pain with any of your teeth?*
Do you have any sores or lumps in or near your mouth?*
Have you had any head, neck, or face injuries?*
Have you experienced clicking/pain in TMJ, difficulty in opening/closing or chewing?*
Do you have frequent headaches?*
Do you clench/grind your teeth?*
Have you had any orthodontic treatment?*
Do you wear dentures/partials?*
Date of placement:
Have you received oral hygiene instructions regarding the care of your teeth and gums?*
Do you have or have you ever had Sleep Apnea?*
I certify that I have read the above information and the questions have been accurately answered to my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the initial bill for services. I agree to be responsible for the payment of all services rendered on my behalf or my dependent's.
Signature*
Date*

MonthDayYear
Date
Should be Empty: