appletree.dental - New Patient Form

New Patient Form Packet
Patient Information
Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
SSN
Sex

MaleFemale
Email address
example@example.com
Mobile phone number
Please enter a valid phone number.Format: (000) 000-0000.
Alt. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Marital Status

SingleMarried
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Information

(If Applicable)
Name

First NameLast Name
Spouse Birthdate

MonthDayYear
Date
Spouse SSN
Spouse Occupation
Spouse Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Employer
Employment Information
Employment Status

Full TimePart TimeSelf EmployedStudentRetiredHome MakerUnemployed
Employer
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardians of Minor

If the patient is not a minor, please disregard this section
Who does the patient live with?

Guardian 1Guardian 2Guardian 1 & 2Other
Guardian 1's Full Name

First NameLast Name
Guardian 1 Relationship to Patient
Guardian 1 Birthdate

MonthDayYear
Date
Guardian 1 SSN
Guardian 1 Sex

MaleFemale
Guardian 1 Email Address
example@example.com
Guardian 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian 1 Alt. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian 1 Address (Including City, State / Province, and Zip / Postal Code)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian 1 Employer
Guardian 1 Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian 1 Relationship to Guardian 2

MarriedSeparatedDivorcedOther
Guardian 2's Full Name

First NameLast Name
Guardian 2 Relationship to Patient
Guardian 2 Birthdate

MonthDayYear
Date
Guardian 2 SSN
Guardian 2 Sex

MaleFemale
Guardian 2 Email Address
example@example.com
Guardian 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian 2 Alt. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian 2 Address (Including City, State / Province, and Zip / Postal Code)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian 2 Employer
Guardian 2 Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party is

Same as Guardian 1Same as Guardian 2Other
Responsible Party / Billing Information

If the patient is the responsible party, please disregard this section
Relationship to Patient
Name

First NameLast Name
Preferred Name
Birthdate

MonthDayYear
Date
SSN
Sex

MaleFemale
Email Address
example@example.com
Address (Including City, State / Province, and Zip / Postal Code)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alt. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Emergency Contact Name
Relationship to Patient
Address (Including City, State / Province, and Zip / Postal Code)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alt. Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Information
Please share with us how you heard about our office. Thank you.

GoogleWebsiteFacebookYelpFamily MemberFriendPediatrician/PhysicianDentist/Dental OfficeInsuranceSchool/DaycareCommunity EventPrint Ad (magazine, newspaper, etc.)Media Ad (radio, movie theater, etc.)Other
Signature
Insurance Information
Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Will you be using insurance?

YesNo
Primary Insurance Information

If you're not using insurance, please disregard this section
Insured's Full Name

First NameLast Name
Insured's Employer
Insured's Birthdate

MonthDayYear
Date
Insured's SSN
Insurance Company
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy Number
Group Number
Insurance Address (Including City, State / Province, and Zip / Postal Code)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance Coverage

If you do not have dual insurance coverage, please disregard this section
Insured's Full Name

First NameLast Name
Insured's Employer
Insured's Birthdate

MonthDayYear
Date
Insured's SSN
Insurance Company
Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy Number
Group Number
Insurance Address (Including City, State / Province, and Zip / Postal Code)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History

Please answer if filling this form out on the day of your appointment
Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently being treated by a physician for a specific condition?

YesNo
If so, please tell us about your treatment
Have you recently been hospitalized or had a major operation?

YesNo
If so, please tell us about the hospitalization
Have you ever had a serious head or neck injury?

YesNo
If so, please tell us about the head/neck injury
Are you taking any medications, pills, or drugs?

YesNo
Please list all medications and dosage
Are you on a special diet?

YesNo
Please tell us about your diet
Do you use tobacco?

YesNo
Please tell us how often and what type of tobacco consumption
Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.
Have you ever been advised that you require antibiotics prior to a dental appointment?

YesNo
Please tell us about the antibiotics
Do you take, or have you taken, PhenFen or Redux?

YesNo
If so, please tell us about your PhenFen/Redux usage
Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates?

YesNo
If so, please tell us about your bisphosphonate usage
Have you recently used controlled substances?

YesNo
If so, please tell us which controlled substances and amount/frequency
Have you recently consumed alcohol?

YesNo
Please tell how much alcohol and how recently
Women (Please check all that apply)

PregnantTrying to get pregnantCurrently nursingTaking oral contraceptivesNone of the above
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic)

AspirinAcrylicErythromycinIodineLatexLocal AnestheticsMetalNovocaineNitrous OxidePenicillinSulfa DrugsTetracyclineValiumXylocaineNone of the AboveOther
Do you have, or have you ever had any of the following medical conditions? (Please select all that apply)

AnemiaChemotherapyCold Sores/Fever BlistersCortisone MedicationExcessive BleedingFrequent CoughFrequent HeadachesHay FeverHemophiliaHigh Blood PressureHives or RashKidney ProblemsLiver DiseaseParathyroid DiseaseRecent Weight LossRheumatismShinglesSpina BifidaStrokeThyroid DiseaseVenereal DiseaseArthritis or GoutBlood DiseaseBruise EasilyCongenital Heart ProblemsDiabetesDrug/Alcohol AddictionEmphysemaFrequent UrinationHeart MurmurHeart Valve or PacemakerHerpesHypoglycemiaLung DiseaseRheumatic FeverTuberculosisUlcers or GI ProblemsAsthmaChest PainsConvulsionsEasily WindedExcessive ThirstFrequent DiarrheaGenital HerpesHeart Attack/Heart FailureHepatitis (B or C)Low Blood PressureIrregular HeartbeatLeukemiaMitral Valve ProlapseRadiation TreatmentsRenal DiseaseScarlet FeverSickle Cell DiseaseStomach/Intestinal DiseaseSwelling of LimbsTonsillitisYellow JaundiceArtificial JointBlood TransfusionCancerCurrently PregnantDizziness or FaintingEating DisorderEpilepsy or SeizuresGlaucomaHeart TroubleHepatitis (A)HIV-AIDS-ARCJaw Joint PainPsychiatric CareSinus ProblemTumor or GrowthX-ray/ChemotherapyNo to All
Do you have any condition or problem, not listed, which we should know about?

YesNo
Please explain
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
Signature
Dental History
Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How do you feel about dental treatment?

RelaxedA little uneasyTenseAnxiousVery Anxious
Have you seen a dentist before?

YesNo
If so, when was your last dental visit?

Within the last 3 monthsWithin the last 3-6 monthsWithin the last 6-9 monthsWithin the last 9-12 monthsMore than 1 year agoMore than 2 years agoMore than 5 years agoNever
How would you rate your previous dental experience?

ExcellentGoodAveragePoor
What are your dental concerns?
Have you avoided regular dental care?

YesNo
If so, why have you avoided regular dental care?
Are you happy with the appearance of your teeth?

YesNo
If not, why are you unhappy with the appearance of your teeth?
How often do you brush?

Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day
How often do you floss?

Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day
How often do you use other aids? water flosser, gum picks, gum stimulator, etc.

Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day
Would you like your teeth to be whiter?

YesNo
Would you like your teeth to be straighter?

YesNo
Do you have, or have you ever had any of the following dental conditions? Please check all that apply.

Aching or sensitive teethActive decay of teeth or gumsAreas of food trapsBad breathBroken fillingBroken or missing teethCavitiesClicking or popping jawCold soresDifficulty opening wideDry mouthAesthetic concerns with teethFacial surgeryGag easilyGrowths or lesions in your mouthGum infection / diseaseGum treatmentsJaw pain or tirednessJaw clenchingLoose teethNight guardOral surgeryOrthodontic treatmentSensitive or bleeding gumsSwelling or lumps in mouthSwollen glandsTeeth grindingUnfavorable dental experienceNone of the above
Previous dentist or dental office
Name of previous dentist or dental office
City
State / Province
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status.
Signature
Authorizations and Acknowledgements

ACKNOWLEDGEMENT OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Private Practices: I (the patient) have the right to read the Privacy Practices. A copy of the Notice and/or this consent is available upon request and anytime on our website. The Notice provides a description of our practice's treatment, payment activities, healthcare operations and the uses and disclosures we make of your protected health information.

Purpose of Consent: I (the patient) understand and consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

Personal protected information cannot be shared with anyone unless otherwise allowed by HIPAA rules.
I have read, understood, and agree to the above statements.
Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Please review to ensure the details are correct before completion.
Should be Empty:

New Patient Form Packet

Patient Information

Spouse Information

Employment Information

Guardians of Minor

Responsible Party / Billing Information

Emergency Contact

Referral Information

Insurance Information

Primary Insurance Information

Secondary Insurance Coverage

Medical History

Dental History

Authorizations and Acknowledgements