New Patient Form

New Patient Form
- SS/HIC/Patient ID #*
- Patient Name*
  
  First NameLast Name
- Patient Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Email*
  example@example.com
- Sex
  
  MaleFemaleOther
- Age*
- Birthdate*
  
  MonthDayYear
  Date
- MarriedWidowedSingleMinorSeparatedDivorcedOther
- Occupation
- Patient Employer/School
- Employer/School Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Employer/School Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Spouse's Name
- Spouse's Birthdate
  
  MonthDayYear
  Date
- Spouse's SS#
- Spouse's Employer
- Whom may we thank for referring you?
- Who is responsible for this account
- Relationship to Patient
- Insurance Co.
- Group #
- Is patient covered by additional insurance?
  
  YesNo
- Subscriber's Name
- Birthdate
  
  MonthDayYear
  Date
- SS#
- Relationship to Patient
- Insurance Co.
- Group #
- ASSIGNMENT AND RELEASE
- I certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr. Doctor's name all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges wether 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.
- Signature of Patient, Parent, Guardian or Personal Representative
- Relationship to Patient
- Home Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Work Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Extension
- Cell Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Spouse's Work
  Please enter a valid phone number.Format: (000) 000-0000.
- Best time and place to reach you
- IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household)
- Name
  
  First NameLast Name
- Relationship
- Home Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Work Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Reason for today's visit
- Former Dentist
- City/State
- Date of last dental visit
  
  MonthDayYear
  Date
- Date of last dental X-rays
  
  MonthDayYear
  Date
- Choose "Yes" or "No" to indicate if you have had any of the following
- Bad breath
  
  YesNo
- Bleeding gums
  
  YesNo
- Blisters on lips or mouth
  
  YesNo
- Blisters on lips or mouth
  
  YesNo
- Burning sensation on tongue
  
  YesNo
- Chew on one side of mouth
  
  YesNo
- Cigarette, pipe or cigar smoking
  
  YesNo
- Clicking or popping jaw
  
  YesNo
- Dry mouth
  
  YesNo
- Fingernail biting
  
  YesNo
- Food collection between the teeth
  
  YesNo
- Foreign objects
  
  YesNo
- Grinding teeth
  
  YesNo
- Gums swollen or tender
  
  YesNo
- Jaw pain or tiredness
  
  YesNo
- Lip or cheek biting
  
  YesNo
- Loose teeth or broken filings
  
  YesNo
- Mouth breathing
  
  YesNo
- Mouth pain, brushing
  
  YesNo
- Orthodontic treatment
  
  YesNo
- Pain around ear
  
  YesNo
- Periodontal treatment
  
  YesNo
- Sensitivity to cold
  
  YesNo
- Sensitivity to heat
  
  YesNo
- Sensitivity to sweets
  
  YesNo
- Sensitivity when biting
  
  YesNo
- Sores or growths in your mouth
  
  YesNo
- How often do you floss?
- How often do you brush?
- Physician's Name
  
  First NameLast Name
- Date of last visit
  
  MonthDayYear
  Date
- Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of Ionimin, Adipex, Fastin, (brand names of phentermine), Pondimin (fenfluramine) and Redux (desfenfluramine)
  
  YesNo
- Place a mark on "yes" or "no" to indicate if you ahve had any of the following:
- AIDS/HIV
  
  YesNo
- Anemia
  
  YesNo
- Arthritis, Rheumatism
  
  YesNo
- Artificial Joints
  
  YesNo
- Asthma
  
  YesNo
- Back Problems
  
  YesNo
- Bleeding abnormally, with 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 or bloody
  
  YesNo
- Diabetes
  
  YesNo
- Emphysema
  
  YesNo
- Epilepsy
  
  YesNo
- Fainting or dizziness
  
  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
- Lowe 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 Feet or Ankles
  
  YesNo
- Swollen Neck Glands
  
  YesNo
- Thyroid Problems
  
  YesNo
- Tonsilitis
  
  YesNo
- Tuberculosis
  
  YesNo
- Tumor or growth on head or neck
  
  YesNo
- Ulcer
  
  YesNo
- Venereal Disease
  
  YesNo
- Weight Loss, unexplained
  
  YesNo
- Do you wear contact lenses?
  
  YesNo
- WOMEN
- Are you pregnant?
  
  YesNo
- Due Date
- Taking birth control pills?
  
  YesNo
- Are you nursing?
  
  YesNo
- List any medications you are currently taking and the correlating diagnosis
- Pharmacy Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Choose any that apply:
  
  AspirinBarbiturates (Sleeping pills)CodeineIodineLatexLocal AnestheticPenicillinSulfaOther
- Should be Empty:

New Patient Form

ASSIGNMENT AND RELEASE

WOMEN