EZ Dental | Returning Patient Forms

EZ Dental | Returning Patient Forms

Thank you for trusting us with your dental care. We promise to do our best to provide you with the finest care available. If you have any questions please do not hesitate to call us.
PATIENT INFORMATION
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ID#/S.S.
Phone Number
Please enter the best phone number to contact you directly.
Birthdate

MonthDayYear
Date
Age
Sex
Please Choose

SingleMarriedWidowedSeparatedDivorced
Patient Employed By
Occupation
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.
Whom may we thank for referring you?
In case of emergency, who should be notified? Enter name and phone number.
PRIMARY INSURANCE

If your insurance information has changed, please fill out the information below.
Subscriber Name

First NameLast Name
Relation to Patient
Birthdate

MonthDayYear
Date
Address (if different from patient's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Employed By
Business Phone
Please enter a valid phone number.
Insurance Company
Group #
Subscriber #
Contract #
Names of other dependents covered under this plan
DENTAL HISTORY
Reason for Today's Visit
Date of Last Dental Care

MonthDayYear
Date
Former Dentist
Date of Last Dental X-Rays

MonthDayYear
Date
Address
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 had any serious illnesses or operations?

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

YesNo
If yes, give approximate dates:
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 (dexfenfluramine)?

YesNo
(Women) Are you pregnant?

YesNo
Are you nursing?

YesNo
Are you 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 HabitCancerHeadachesPacemakerTonsilitisChemical DependencyHeart MurmurRadiation TreatmentTuberculosisChemotherapyHeart ProblemsRespiratory DiseaseUlcerCirculatory ProblemsHemophiliaRheumatic FeverVenereal Disease
Please list the medications you are currently taking:
Please list any allergies you have:
By signing, I confirm that the information entered is properly updated and correct to the best of my knowledge.
Printed Name

First NameLast Name
Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

EZ Dental | Returning Patient Forms

PATIENT INFORMATION

PRIMARY INSURANCE

DENTAL HISTORY

MEDICAL HISTORY