Patient Information (CONFIDENTIAL)
Date
-
Month
-
Day
Year
Date
Soc. Sec. #
Birth Date
*
Please select a month
January
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Month
Please select a day
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Day
Please select a year
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Year
Name
Home Phone
Cell Phone
Address
City
State
Zip
E-mail:
*
Check Appropriate Box:
Minor
Single
Married
If Student, Name of School / College
State
City
Fulll Time
Part Time
Patient’s or Parent’s Employer
Work Phone
Please enter a valid phone number.
Business Address
City
State
Zip
Spouse or Parent’s Name
Employer
Work Phone:
Whom may we thank for referring you?
Person to Contact in Case of Emergency
Type a question
Phone
Responsible Party
Name of Person Responsible for this Account
Relationship to Patient
Address
Home Phone
Driver’s License #
Date
-
Month
-
Day
Year
Date Picker Icon
Employer
Employer
Work Phone
SSN#
Is this person currently a patient in our office?
Yes
No
IT IS THE POLICY OF THIS OFFICE TO MAKE DEFINITE FINANCIAL ARRANGEMENTS BEFORE ANY MAJOR WORK IS STARTED. IN ALLCASES REQUIRING LAB WORK SUCH AS CROWNS, DENTURES, OR BRIDGES WE REQUEST A MINIMUM DOWN PAYMENT OF 50%.
Insurance Information
Name of Insured
Relationship to Patient
Birthdate
-
Month
-
Day
Year
Date Picker Icon
Social Security #
Date Employed
-
Month
-
Day
Year
Date Picker Icon
Address of Employer
City
State
Zip
Insurance Company
Group #
Policy / ID #
Ins. Co. Address
City
Zip
Insurance Company Phone #
How much is your deductible?
Max. Annual Benefit
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 thediagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payorsand/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefitsotherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsiblefor payment of all services rendered on my behalf or my dependents.
Signature of patient (or parent if minor)
Patient Medical History
Physician
Office Phone
Date of Last Exam
-
Month
-
Day
Year
1. Are you under medical treatment now?
Yes
No
2. Have you been hospitalized for any surgicaloperation or serious illness within the last 5 years?
Yes
No
If yes, please explain
3. Are you taking any medication(s) includingnon-prescription medications?
Yes
No
If yes, what medication(s) are you taking
4. Do you use tobacco?
Yes
No
5. Are you allergic to or have you had any reactions to the following?
Yes
No
Local Anesthetics (e.g. Novocaine)
Yes
No
Penicillin or any other Antibiotic
Yes
No
Sulfa Drugs
Yes
No
Barbiturates
Yes
No
Sedatives
Yes
No
Iodine
Yes
No
Sedatives
Yes
No
Aspirin
Yes
No
Any Metals (e.g. nickel, mercury, etc
Yes
No
Latex Rubber
Yes
No
Other (please list)
Yes
No
6. Women Only: Are you pregnant or think you may be pregnant?
Yes
No
* For those patients using oral contraceptives: Please be advised that the use of certain antibiotics can reduce the effectiveness of Birth Control.If you have concerns, please speak with the doctor.
Do you have or have you had any of the following?
High Blood Pressure
Yes
No
Heart Attack
Yes
No
Rheumatic Fever
Yes
No
Swollen Ankles.
Yes
No
Fainting / Seizures
Yes
No
Asthma
Yes
No
Epilepsy / Convulsions
Yes
No
Leukemia
Yes
No
Diabetes
Yes
No
Kidney Diseases
Yes
No
AIDS or HIV Infection
Yes
No
Thyroid Problem .
Yes
No
Heart Disease
Yes
No
Cardiac Pacemaker
Yes
No
Heart Murmur
Yes
No
Angina
Yes
No
Frequently Tired
Yes
No
Anemia
Yes
No
Emphysema
Yes
No
Cancer
Yes
No
Arthritis
Yes
No
Joint Replacement or Implant
Yes
No
Hepatitis / Jaundice
Yes
No
Sexually Transmitted Disease
Yes
No
Stomach Troubles / Ulcers
Yes
No
Chest Pains
Yes
No
Easily Winded
Yes
No
Stroke
Yes
No
Hay Fever / Allergies
Yes
No
Tuberculosis
Yes
No
Radiation Therapy
Yes
No
Glaucoma
Yes
No
Recent Weight Loss
Yes
No
Liver Disease
Yes
No
Other
Yes
No
Respiratory Problems
Yes
No
Heart Trouble
Yes
No
Mitral Valve Prolapse
Yes
No
Patient Dental History
Reason for todays visit?
Last Dental visit (date)?
-
Month
-
Day
Year
Date
For What Reason?
Previous Dentist?
1. Do your gums bleed while brushing or flossing?
Yes
No
2. Are your teeth sensitive to hot or cold liquids/foods?
Yes
No
3. Are your teeth sensitve to sweet or sour liquids / foods?
Yes
No
4. Do you feel pain in any of your teeth
Yes
No
5. Do you have any sores or lumps in or near your mouth?
Yes
No
6. Have you had any head, neck or jaw injuries?
Yes
No
7. Have you ever experienced any of the following problemsin your jaw?
Yes
No
Clicking
Yes
No
Pain (joint, ear, side or face)
Yes
No
Difficulty in opening or closing
Yes
No
Difficulty in chewing
Yes
No
8. Do you have frequent headaches?
Yes
No
9. Do you clench or grind your teeth?
Yes
No
10. Do you bite your lips or cheeks frequently?
Yes
No
11. Have you ever had prolonged bleeding followingextractions?
Yes
No
12. Have you had any orthodontic treatment?
Yes
No
13. Do you wear dentures or partials?
Yes
No
If yes, date of placement
14. Have you ever received oral hygiene instructionsregarding the care of your teeth and gums?
15. Do you like your smile?
16. If by magic, you could change anything about your teeth,what would you change?
Additional Comments
Submit
Should be Empty: