Dr. Kulaga - New Patient Form - White Wolf Dental

Patient Information

Fill out the form carefully for registration
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Social Security #*
Patient Status*

MarriedSingleChildOther
Phone (Cell)*
Phone (Home)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Driver's License #*
When confirming appointments how do you prefer to be contacted?*

PhoneEmailText Msg
Patient or Parent's Employer
Emergency Contact Name
Emergency Contact Phone*
Emergency Contact Relationship
Responsible Party
Is the patient responsible for this account?*

YesNo
Name of Person Responsible for this Account
Relationship to Patient
Contact Phone*
Birth Date*

MonthDayYear
Employer
Social Security #*
Work Phone*
Is this Person Currently a Patient in our Office?*

YesNo
For your convenience we offer the following methods of payment. Please check the option you prefer.

CashPersonal CheckVisa/MastercardDiscoverCareCredit®
How did you hear about our office? (Check All That Apply)

TVGoogleWebsitePrint AdDrive ByFacebookFriendPatient
Friend Referral Name
Patient Referral Name
Medical Health History

Fill out the form carefully for registration
Physician's Name
Office Phone*
Please enter a valid phone number.
When was your last Dental visit? *

MonthDayYear
Date
Are you under medical treatment now?*

YesNo
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?*

YesNo
If yes, please explain
Are you taking any medication(s) including non-prescription medicine?*

YesNo
If yes, what medications are you taking?
Are you currently taking or have you ever taken osteoporosis medications in the past?*

YesNo
If so, how long ago and for how long did you take them?
Which medications?
Do you use Tobacco?*

YesNo
Do you use controlled substances or recreational drugs?*

YesNo
Are you allergic to any of the following?
Local Anesthetics (e.g. novocaine)*

YesNo
Penicillin*

YesNo
Other Antibiotics*

YesNo
Which antibiotics?
Sulfa Drugs*

YesNo
Sedatives*

YesNo
Iodine*

YesNo
Ibuprofen*

YesNo
Tylenol*

YesNo
Codeine*

YesNo
Any Metals (e.g. nickel, mercury, etc.)*

YesNo
Latex Rubber*

YesNo
Other*

YesNo
Please list:
Do you have or have you had any of the following?
High Blood Pressure*

YesNo
Heart Attack*

YesNo
Rheumatic Fever*

YesNo
Swollen Ankles*

YesNo
Fainting*

YesNo
Seizures*

YesNo
Low Blood Pressure*

YesNo
Epilepsy / Convulsions*

YesNo
Cancer*

YesNo
Radiation Therapy*

YesNo
Diabetes*

YesNo
Kidney Diseases*

YesNo
AIDS or HIV infection*

YesNo
Thyroid Problem*

YesNo
Sight Impaired*

YesNo
Hearing Impaired*

YesNo
Heart Disease*

YesNo
Mitral Valve Prolapse*

YesNo
Congestive Heart Failure*

YesNo
Cardiac Pacemaker*

YesNo
Heart Murmur*

YesNo
Frequently Tired*

YesNo
Angina*

YesNo
Anemia*

YesNo
Ephysema / COPD*

YesNo
Tuberculosis*

YesNo
Asthma*

YesNo
Arthritis*

YesNo
Joint Replacement or Implant*

YesNo
Hepatitis / Jaundice*

YesNo
Sexually Transmitted Disease*

YesNo
Stomach Troubles / Ulcers*

YesNo
Vertigo*

YesNo
Neck Pain*

YesNo
Back Pain*

YesNo
Chest Pains*

YesNo
Easily Winded*

YesNo
Stroke*

YesNo
Hay Fever / Allergies*

YesNo
Glaucoma*

YesNo
Recent Weight Loss*

YesNo
Liver Disease*

YesNo
Other medical conditions
Please describe any medical conditions you have that are not listed
Patient Dental History
Name of Previous Dentist/Location
Date of Last Exam/Cleaning*

MonthDayYear
Date
Do your gums bleed while brushing or flossing?*

YesNo
Are your teeth sensitive to hot or cold liquids/foods?*

YesNo
Are your teeth sensitive to sweet or sour liquids/foods?*

YesNo
Do you feel pain to any of your teeth?*

YesNo
Do you have any sores or lumps in or near your mouth?*

YesNo
Have you had any head, neck or jaw injuries?*

YesNo
Have you ever experienced any of the following problems in your jaw? (Select ALL thet apply)

ClickingPain (joint, ear, side of face)Difficulty in opening or closingDifficulty in chewing
Do you have frequent headaches?*

YesNo
Do you clench or grind your teeth?*

YesNo
Do you bite your lips or cheeks frequently?*

YesNo
Have you ever had any difficult extractions in the past?*

YesNo
Have you ever had any prolonged bleeding following extractions?*

YesNo
Have you had any orthodontic treatment?*

YesNo
Do you wear dentures or partials?*

YesNo
If yes, date of placement:*

MonthDayYear
Date
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?*

YesNo
Do you like your smile?*

YesNo
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand
that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records
of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I agree
to be responsible for payment of all service rendered on my behalf of my dependents.
Signature of Patient, Parent or Guardian*

Clear
Date*

MonthDayYear
Date
Acknowledgement of Reciept of Notice of Privacy Practice
HIPAA
I hereby acknowlege that I have received and had an opportunity to ask questions concerning White Wolf Dental Group's Notice of PrivacyPractice.
Patient Signature*

Clear
Patient's Name
Date*

MonthDayYear
Date
If signed by a representative, name of representative
Relationship to Patient
Should be Empty:

Patient Information

Responsible Party

Medical Health History

Are you allergic to any of the following?

Do you have or have you had any of the following?

Patient Dental History

Authorization and Release

Acknowledgement of Reciept of Notice of Privacy Practice

HIPAA