dentalcarestl.com-Patient Form

Patient Information
Date

MonthDayYear
Date
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alt. Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameMiddle NameLast Name
SS/HIC/Patient ID #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Sex

MF
Age
Birthdate

MonthDayYear
Date
Marital Status

MarriedWidowedSingleMinorSeparatedDivorcedPartnered for Years
Patient Employer/School
Occupation
Employer/School Address
Employer/School Phone
Whom may we thank for referring you?
In case of emergency who should be notified?
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insurance
Person Responsible for Account

First NameMiddle NameLast Name
Relation to Patient
Birthdate

MonthDayYear
Date
Soc. Sec. #
Address (If different from patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Employed by
Occupation
Business Address
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
Contract #
Please enter a valid phone number.Format: (000) 000-0000.
Group #
Subscriber #
Names of other dependents covered under this plan
Additional Insurance
Is patient covered by additional insurance?

YesNo
Subscriber Name
Birthdate

MonthDayYear
Date
Relation to Patient
Address (If different from patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber Employed by
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
Soc. Sec. #
Contract #
Group #
Subscriber #
Names of other dependents covered under this plan.
Dental History
Reason for Today's Visit
Date of last dental care
Former Dentist
Date of last dental X-rays
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check (✓) if you have had problems with any of the following:

Bad breathGrinding teethSensitivity to hotBleeding gumsLoose teeth or broken fillingsSensitivity to sweetsClicking or popping JawPeriodontal treatmentSensitivity when bitingFood collection between teethSensitivity to coldSores or growths in your mouth
How often do you floss?
How often do you brush?
Medical History
Physician's Name
Date of Last Visit

MonthDayYear
Date
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.

YesNo
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).

YesNo
Have you had any serious illnesses or operations?

YesNo
If yes, describe
Have you ever had a blood transfusion?

YesNo
If yes, give approximate dates
(Women) Are you pregnant?

YesNo
Nursing?

YesNo
Taking birth control pills?

YesNo
Check (✓) if you have or have had any of the following:

AnemiaCortisone TreatmentsHepatitisScarlet FeverArthritis, RheumatismCough, PersistentHigh Blood PressureShortness of BreathArtificial Heart ValvesCough up BloodHIV/AIDSSkin RashArtificial JointsDiabetesJaw PainStrokeAsthmaEpilepsyKidney DiseaseSwelling of Feet or AnklesBack ProblemsFaintingLiver DiseaseThyroid ProblemsBlood DiseaseGlaucomaMitral Valve ProlapseTobacco HabitCancerHeadachesPacemakerTonsillitisChemical DependencyHeart MurmurRadiation TreatmentTuberculosisChemotherapyHeart ProblemsRespiratory DiseaseUlcerCirculatory ProblemsHemophiliaRheumatic FeverVenereal Disease
MEDICATIONS: List medications you are currently taking:
ALLERGIES
Authorization
I certify that I, and/or my dependent(s), have insurance coverage with
Name of Insurance Company(ies) and assign directly to Dr blank 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.
Signature of Patient, Parent. Guardian or Personal Representative
Date

MonthDayYear
Date
Please print name of Patient, Parent. Guardian or Personal Representative
Relationship to Patient
Payment is due in full at time of treatment unless prior arrangements have been approved.
Should be Empty:

Patient Information

Primary Insurance

Additional Insurance

Dental History

Medical History

Authorization