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Welcome
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Patient Information Date_________________
Name___________________________________________________________________ Age__________________
First Middle Last
Mailing Address__________________________________City_________________State_______Zip_____________
Home Phone #______________________Work #_____________________ Cell Phone #________________________________
Do you prefer to receive calls at: (Home (Work (Cell Phone E-MAIL:_______________________________________
Preferred Name____________________ Birth-date___________________ Sex: ( Male ( Female
Are you: ( Minor ( Married ( Divorced ( Widowed ( Single ( Separated
Driver’s License #:_______________________ Social Security # (not needed for minors)________________________________
Your employer:____________________________________ Occupation:___________________________________
Your Parent’s employer (if minor):____________________________________ Occupation:____________________
Parent(s)’s Name(s) (if minor):_____________________________________________ Work #(s):_______________
Spouse’s Name (if applicable):_____________________________________________ Work #__________________
Person to contact in case of emergency:______________________________________ Phone #__________________
Whom may we thank for referring you to us?______________________________________________________
Insurance Information
Employee’s Name:_________________________________________ Relationship to patient:___________________
Birth-date:______________ Social Security #:_____________________ Contact #:___________________________
Name of Employer:_______________________ Insurance Co.:___________________________________________
Subscriber ID#_________________________ Group#_____________________ Ins. Ph#______________________
DO YOU HAVE ADDITIONAL INS.? ( No ( Yes IF YES, PLEASE COMPLETE THE FOLLOWING:
Employee’s Name:_________________________________________ Relationship to patient:___________________
Birth-date:______________ Social Security #:_____________________ Contact #:___________________________
Name of Employer:_______________________ Insurance Co.:___________________________________________
Subscriber ID#_________________________ Group#_____________________ Ins. Ph#______________________
Dental History
Former Dentist:_________________ Reason for today’s visit:________________Date of last exam:______________
Date of last dental X-rays:____________How often do you brush?____________How often do you floss?_________
Please check any of the following conditions that apply to you:
( Bad Breath ( Grinding Teeth ( Sensitivity to hot
( Bleeding Gums ( Loose teeth/broken fillings ( Sensitivity to sweets
( Clicking or popping jaw ( Periodontal treatment ( Sensitivity when biting
( Food collection between teeth ( Sores/growths in your mouth ( Sensitivity to cold
( Orthodontics ( Reaction to antibiotics, pain medicine or local anesthetic
I would like more information on the following:
⇨ whitening my front teeth ( orthodontics ( improving the look of my front teeth
⇨ other topics ______________________________________________________________________________________
Medical History
Physician:_________________________________________________ Date of last visit:_______________________
Are you taking any medications? ( Yes ( No
If yes, please list meds & what they are for:____________________________________________________________
Do you have any Allergies (i.e. Meds, latex)? ( Yes ( No If yes, please list:___________________________
______________________________________________________________________________________________
(Women) Are you pregnant? ( Yes ( No Nursing? ( Yes ( No Taking birth control pills? ( Yes ( No
Do you have a history of the following?
⇨ AIDS ( Coughing up blood ( High Blood Pressure ( Radiation Treatment
⇨ Anemia ( Diabetes ( HIV (+) ( Respiratory Disease
⇨ Artificial Heart Valves ( Epilepsy ( Excessive Bleeding ( Rheumatic Fever
⇨ Artificial Joints ( Fainting ( Jaw Pain/Noise ( Scarlet Fever
⇨ Asthma ( Glaucoma ( Kidney Disease ( Seasonal Allergies
( Back Problems ( Head Injuries ( Latex Allergy ( Skin Rash
⇨ Blood Disease ( Heart Murmur ( Liver Disease ( Stroke
⇨ Cancer ( Heart Problems ( Mitral Valve Prolapse ( Tobacco Habit
⇨ Chemical Dependency Describe_________ ( Nervous Problems ( Tuberculosis
⇨ Chemotherapy ________________ ( Pacemaker ( Venereal Disease
⇨ Circulatory Problems ( Hepatitis ( Psychiatric Care ( NONE
Have you ever had any serious illnesses or operations? ( Yes ( No If yes, describe:______________________
Have you ever had a blood transfusion? ( Yes ( No If yes, give approx. date:___________________________
Have you ever been told by a physician you need to be pre-medicated with antibiotics prior to medical/dental treatment? (normally due to heart murmurs, other heart issues or artificial joints) ( Yes ( No
Authorization
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I also agree that my portion of services will be paid at the time of treatment.
X__________________________________ _________________________
Signature of Patient (or parent if a Minor) Date
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