drkolanderdds.com - New Patient Form

Patient Form
Patient Information
Date

MonthDayYear
Date
SS/HIC/Patient ID #
Patient Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Sex

MaleFemale
Age
Birthdate

MonthDayYear
Date
Marital Status

MarriedWidowedSeparatedDivorcedSingleMinorPartnered
How many years you have been partnered?
Patient Employer/ School
Occupation
Employer/ School Address
Employer/ School Phone
Please enter a valid phone number.
Spouse's Name
Birthdate

MonthDayYear
Date
SS#
Spouse's Employer
Whom may we thank for referring you?
Dental Insurance
Who is responsible for this account?
Relationship to Patient
Insurance Co.
Group #
Is patient covered by additional insurance?

YesNo
Subscriber's Name
Birthdate

MonthDayYear
Date
SS#
Relationship to Patient
Insurance Co.
Group #
ASSIGNMENT AND RELEASE

I certify that l, and/or my dependent(s), have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr. Dr. Name all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible lor 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

Clear
Name of Patient, Parent, Guardian or Personal Representative
Date

MonthDayYear
Date
Relationship to Patient
Phone Numbers
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Alt. Phone Number
Please enter a valid phone number.
Spouse's Work Number
Please enter a valid phone number.
Best time and place to reach you
lN CASE OF EMERGENCY CONTACT (Specify someone who does not live in your household.)
Name:
Relationship:
Phone Number:
Please enter a valid phone number.
Alt. Phone Number:
Please enter a valid phone number.
Dental History
Reason for today's visit
Former Dentist
City/State
Date of last dental visit

MonthDayYear
Date
Date of last dental X-rays

MonthDayYear
Date

Place a check mark on "yes" or "no" to indicate if you have had any of the following:

	Yes	No
Bad breath
Bleeding gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growths in your mouth

How often do you floss?
How often do you brush?

	Yes	No
Service Quality
AIDS/HIV
Anemia
Arthritis, Rheumatism
Artificial Heait Valves
Artificial Joints
Asthma
Back Problems
Bleeding abnormally, with extractions or surgery
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, persistent or bloody
Diabetes
Emphysema
Do you wear contact lenses?
Epilepsy
Fainting or dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hepatitis
Herpes
High Blood Pressure
Jaundice
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Special Diet
Stroke
Swollen Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor or growth on head or neck
Ulcer
Venereal Disease
Weight Loss, unexplained

Patient Form

Patient Information

Dental Insurance

Phone Numbers

Dental History

Dental Registration and History

Health History

Medications

Allergies

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