New Patient Information

New Patient Information

Form 1/4
1. Patient Information
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Date
Preferred Name
MaleFemalePrefer not to identify
SSN
Address

Address

Street Address Line 2

CityState

Zip Code
Home Phone
Cell Phone
Work Phone
Email
example@example.com
Satisfaction Regarding Current Smile:

Extremely satisfiedVerySomewhatNot veryNot at all satisfied
2. Responsible Party
Relationship to Patient:

SelfParent/GuardianOther
Mark 'Self' if patient is the same as the Responsible Party and skip this section.
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Date
SSN
Address

Address

Street Address Line 2

CityState

Zip Code
Home Phone
Cell Phone
Work Phone
Email
example@example.com
3. Other Members of Household
By providing the phone number(s) above, I expressly consent to receiving telephone calls, text messages, and/or email messages from the Practice and its agents and representatives via an automatic telephone dialing system, other computerassisted technology, pre-recorded message(s), for any purpose, including, but not limited to, appointment and follow-up health care reminders, scheduling, patient account(s), assignment of benefits, financial responsibility and/or marketing messages. I understand that, depending on my phone plan, I could be charged for these calls or text messages. I agree to provide new number(s) if my number(s) change.
4. Primary Dental Insurance
Subscribers Name
Subscribers SSN
Subscribers Birth Date

MonthDayYear
Date
Address

Subscribers Address

Street Address Line 2

CityState

Zip Code
Employer
Insurance ID
Employer ID
Insurance Company Name
Address
Insurance Company Phone
Insurance Company Group
5. Please take a picture of the front and back of your insurance card and upload here.

Cancelof
6. Secondary Dental Insurance
Subscribers Name
Subscribers SSN
Subscribers Birth Date

MonthDayYear
Date
Employer
Insurance ID
Insurance Company Name
State
Insurance Company Phone
Insurance Company Group
7. Please take a picture of the front and back of your insurance card and upload here.

Cancelof
8. Primary Dental Practice Information
Practice Name
Dentist Name
Date of Last Cleaning

MonthDayYear
Date
Is there pending treatment

YesNo
If yes please explain
Health History Information

9.Check all that apply

	Yes
Abnormal Bleeding
Asthma
Convulsions/Epilepsy
Handicaps/Disabilities
Hemophilia
Jaw Clicking
Metal Allergies
Scarlet Fever
None
Allergies to any Drugs
Cancer
Diabetes
Hearing Impaired
Hepatitis A, B, or C
Kidney/Liver Problems
Pregnant
Smoking/Tobacco
Anorexia/Bulimia
Congenital Heart Defect
Finger Sucking
Heart Murmur
HIV Positive/AIDS
Latex Allergy
Rheumatic Fever
Tuberculosis

10. Please list current medications
11. Please list any known drug allergies
12. Have you ever taken any medications for osteoporosis?
13. Please explain any of the above or list any special needs or concerns
Should be Empty:

New Patient Information

1. Patient Information

2. Responsible Party

3. Other Members of Household

4. Primary Dental Insurance

6. Secondary Dental Insurance

8. Primary Dental Practice Information

Health History Information