PATIENT INFORMATION
Full Name
*
First Name
Last Name
Preferred Pronoun
Nickname
Birth Date
/
Month
/
Day
Year
Date
Gender
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone No
*
Format: (000) 000-0000.
Emergency Contact
*
Phone
Format: (000) 000-0000.
How would you like your appointments confirmed?
Phone
Email
Text
How did you hear about us?
I live/work in area
Social Media
Referred by another clinic
Smile Incentive Program
Student Plan
Word of Mouth
Events
Google
INSURANCE INFORMATION
No Dental Insurance
Primary Insurance
Name of Insurance Company
Birth Date
/
Month
/
Day
Year
Date
Member ID
Carrier
Group/Policy #
Secondary Insurance
Name of Insurance Company
Birth Date
/
Month
/
Day
Year
Date
Member ID
Carrier
Group/Policy #
BILLING
Dental Choice offers the following payment options. Please choose which option you'd like participate in.
Option 1 - This requires you to pay in full on the day of treatment. We accept Visa, Mastercard, Cash and Debit. Our dental Our dental administrative staff will assist you with preparing and submitting claims to your insurance if necessary.
Option 2 - This option allows your insurance to be billed directly and any outstanding amount not covered are the responsibility of the patient and will be collected on the day of service. For this option a credit card is required.
MEDICAL HISTORY
Please check off any of the following conditions you have had (all information remains confidential):
Diabetes
Heart Condition
Shortness of Breath
Liver Disease
HIV/AIDS
Ulcers
Thyroid Disease
Anxiety
Depression
Fainting/Seizures
Osteoporosis
High Blood Pressure
Asthma
Stroke
Cancer/Tumors
Autoimmune Disorder
Chest Pains
Low Blood Pressure
Lung Disease
Kidney Disease
Arthritis
Jaundice
Hepatitis A, B, C
Rheumatic Fever
NONE
Other
1. Are you pregnant? If so, which trimester:
Are you breastfeeding?
Yes
No
2. Are you under the care of a physician for a specific chronic condition?
Yes
No
If so please specify
Date of last check up
/
Month
/
Day
Year
Date
3. Have you had any major surgeries in the last 2 years ? If so, please list:
4. Do you smoke or chew tobacco products?
Yes
No
5. Do you smoke or use by-products of Cannabis?
Yes
No
6. Drug allergies, reactions and/or injections?
7. Are you currently taking ANY medications?
8. Do you have a prosthetic or artificial joint?
9. Rate your smile from 1-10 (10 being the highest):
10. How would you rate yourself as a dental patient?
Calm
Somewhat Anxious
Very Anxious
DENTAL HISTORY
Have you ever had abnormal bleeding associated with previous extractions, surgery, or trauma?
Yes
No
When was your last dental examination and cleaning?
When were your last dental x-rays taken?
Have you noticed any signs of the following?
Bleeding/Swelling of Gums
Gum Ache
Receding Gums
Loose or Broken Teeth
Drifting Teeth
Bad Breath
Sensitivity of Teeth
Dry Mouth
Jaw Pain/Noise
What is the most important concern to you today?
Cost
Time
Appearance
Discomfort
Other
Are you interested in
Sedation
Invisalign
Other
Signature
Todays Date
/
Month
/
Day
Year
Date
I consent that all the information stated above is correct and
filled out to the best of knowledge.
Preview PDF
Submit
Should be Empty: