sugarlanddental.com - New Patient Form

Welcome to Sugar Land Dental
Date

MonthDayYear
Date
Name

PrefixFirst NameMiddle NameLast Name
Preferred Name
Home Address

Street Address

Apt #

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date Of Birth

MonthDayYear
Date
Sex

MaleFemale
Social Security Number
Driver's Licence Number
Place of Employment
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Insurance Information
Insurance:
Insurance Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Policy Holder's First and Last Name:

First NameLast Name
Policy Holder's Date Of Birth:

MonthDayYear
Date
Policy Holder's Social Security Number:
Emergency Contact Info
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about our office?
If patient is a minor, please complete this following information:
Responsible Person's Name

First NameMiddle NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Social Security Number
D.O.B.

MonthDayYear
Date
Driver's License Number
Relationship To Patient
Place of Employment
Medical History
Are you under a physician's care now?

YesNo
Why?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you ever been hospitalized or had a major operation?

YesNo
Discuss
Have you ever had a serious injury to your head or neck?

YesNo
Discuss
Are you taking any medications, pills or drugs?

YesNo
Please list:
Are you on a special diet?

YesNo
Discuss
Do you smoke or use smokeless tobacco or have smoked in the past?

YesNo
How much per day?
What Type:
Are you allergic to any medications or substances?

YesNo
Please check all that apply:

AspirinPenicilinCodeineNovocaineAcrylicMetalLatex RubberOther
WOMEN
Pregnant/ Trying to get pregnant?

YesNo
How far along if pregnant; Nursing;
Taking oral contraceptives?

YesNo
Do you now have or have your ever had any of the following? Please check if appropriate.

AnemiaArtificial Heart ValueArtificial Joint/ImplantAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsCancerChemotherapyDiabetesEmphysemaEpilepsy/ SeizureGlaucomaHeart MurmurHeart SurgeryHeart TroubleHemophiliaHepatitis A, B or CHigh Blood PressureHigh CholesterolHIV PositiveHyperthyroidHypothyroidImmune DeficienciesKidney DiseaseLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapsePacemakerPain in jaw jointsPsychiatric CareRadiationRecurrent InfectionsRheumatic FeverStrokeTuberculosisTumors/ GrowthsVenereal Disease
Do you wish to talk to the dentist privately about any problems?

YesNo
To the best of my knowledge, all of the preceding answers are correct. If i have any changes in my health status or if any medicines change. I shall inform the dentist and staff at the next appointment without fail.
Patient Signature(parent or guardian if the patient is a minor)
Date

MonthDayYear
Date
Should be Empty:

Welcome to Sugar Land Dental

Insurance Information

Emergency Contact Info

Medical History

WOMEN