Patient Information

Patient Information

Complete your details for your dental new-patient visit, including contact, insurance, medical history, and consent.
ABOUT YOU
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
File #
Patient Name

First NameMiddle NameLast Name
What You Prefer To Be Called
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
SS#
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / 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.
Work Phone Ext
Other Phone #s
Please enter a valid phone number.Format: (000) 000-0000.
E-mail Address
example@example.com
Referred By
Employer
How Long at employer
Employer's Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Occupation
Status
Spouse's Name
Do you have children?
How many children?
INSURANCE INFO
Primary Dental Insurance Company Name
Primary Dental Insurance Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Dental Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insured's Identification Number
Primary Group / Plan / Local / Policy Number
Primary Insured's Name
Primary Relation to Insured
Primary Insured's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Insured's Employer
Secondary Dental Insurance Company Name
Secondary Dental Insurance Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Secondary Dental Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Insured's Identification Number
Secondary Group / Plan / Local / Policy Number
Secondary Insured's Name
Secondary Relation to Insured
Secondary Insured's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Insured's Employer
ACCOUNT INFO
Account Holder Name

First NameLast Name
Relation to Patient
Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Government ID Number
Driver License Number
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Payment Method
Payment Account Number
Payment Expiration
Initials
Authorization
IN EVENT OF EMERGENCY
Who should we contact?
Relation
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Who is your Medical Doctor?
M.D.'s Phone #
Please enter a valid phone number.Format: (000) 000-0000.
DENTAL INFORMATION
Reason for today's visit
Are you in pain?
How long in pain?
Please indicate any of the following problems

Other
Other problem
Do you require pre-medication?
Previous dentist name
Previous dentist phone #
Please enter a valid phone number.Format: (000) 000-0000.
Last dental exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last dental x-rays

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Times a day you brush
Times a week you floss
Tooth brush bristles
Rate your smile

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
MEDICAL HISTORY
Medications currently taking
Other medication
Heart Attack / Stroke
Heart Surg./Pacemaker
Heart Murmur
Rheumatic Fever
Mitral Valve Prolapse
Artificial Valves
Heart Disease
Congenital Heart Defect
Chest Pains
Scarlet Fever
Kidney Problems
Liver Problems
Respiratory Problems
Sinus Problems
Stomach Problems/Ulcers
Psychiatric Problems
Venereal Disease
Alcohol/Drug Abuse
Tuberculosis TB
Jaw Problems TMJ/TMD
Cancer/Tumors
Shingles
Hepatitis
HIV+/AIDS/ARC
Arthritis/Rheumatism
Artificial Bones/Joints
Emphysema
Fainting/Seizures/Epilepsy
Severe/Frequent Headaches
Frequent Neck Pain
Chemotherapy
Asthma
Difficulty Breathing
Diabetes/Hypoglycemia
Leukemia
Anemia
High/Low Blood Pressure
Bleeding Problems
Glaucoma
Back Problems
Please list any other medical condition(s)
Allergies
Other allergies
Do you use tobacco?
If yes, how used?
How much?
How long?
Rate your general health (1-10)
Do you wear contact lenses?
Have you ever taken Phen-fen and/or Redux?
Are you taking birth control pills?
How many children have you had?
Are you pregnant?
If pregnant, how long?
Are you nursing?
CONSENT / SIGNATURE
Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
Signing as
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Patient Information

ABOUT YOU

INSURANCE INFO

ACCOUNT INFO

IN EVENT OF EMERGENCY

DENTAL INFORMATION

MEDICAL HISTORY

CONSENT / SIGNATURE