Patient Form

Title :
- Mr.
- Mrs.
- Ms.
- Dr.
Patient Name :*
First Name : Last Name :
I prefer to be called :
Sex :
- Male
- Female
Your birthday :*
MM slash DD slash YYYY
Age:
SSN :
Marital Status :
- Single
- Married
- Partnered
- Divorced/Separated
- Widowed
*Home Address :*
Street Address City State ZIP Code
Email address :*
Home Phone:*
Work Phone:
Cell Phone :
Driver’s license# :
Employer :
Employer Address:
Street Address Address Line 2 City State ZIP Code
How long there ?
Occupation :
Previous dentist :
Present dentist :
Where & when are best times to reach you?
How did you hear about us?
Have you visited our website?
- Yes
- No
Whom may we Thank for referring you?
Other family members seen by us :
Person responsible for account :
Spouse Information
His / Her name :
Employer :
Birthday :
MM slash DD slash YYYY
SSN :
Driver’s license# :
Work Phone:
Relative or friend not living with you
His / Her Name :
Relationship :
Home Phone :
Work Phone :
Medical History
Do you have a personal physician?
- Yes
- No
Physician’s Name :
Date of last visit :
MM slash DD slash YYYY
Home Phone:
Your current physical health is :
- Good
- Fair
- Poor
Are you currently under the care of a physician?
- Yes
- No
If Yes, Please Explain :
Do you smoke or use tobacco in any other form?
- Yes
- No
Have you had any metal rods, pins or implants?
- Yes
- No
Are you taking any prescription / Over-the-counter drugs?
- Yes
- No
If Yes, Please Explain :
Have you ever taken Fosamax, or any other bisphosphonate?
- Yes
- No
Have you ever taken Phen-fen?
- Yes
- No
Are you wearing contact lenses?
- Yes
- No
Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?
- Yes
- No
FOR WOMEN -
Are you using a prescribed method of birth control?
- Yes
- No
Are you pregnant? Week # :
- Yes
- No
Are you nursing?
- Yes
- No
Have you ever had any of the following diseases or medical problems -
Abnormal Bleeding / Hemophilia
- Yes
- No
HIV
- Yes
- No
AIDS
- Yes
- No
Hospitalized for any reason
- Yes
- No
Alcohol / Drug abuse
- Yes
- No
Kidney problems
- Yes
- No
Anemia
- Yes
- No
Liver disease
- Yes
- No
Arthritis
- Yes
- No
Low blood pressure
- Yes
- No
Artificial bones / Joints / Valves
- Yes
- No
Lupus
- Yes
- No
Asthma
- Yes
- No
Sexually Transmitted Disease
- Yes
- No
Blood transfusion
- Yes
- No
Chest Pains
- Yes
- No
Cancer / Chemotherapy
- Yes
- No
Easily Winded
- Yes
- No
Colitis
- Yes
- No
Mitral valve prolapse
- Yes
- No
Congenital heart defect
- Yes
- No
Pacemaker
- Yes
- No
Diabetes
- Yes
- No
Psychiatric problems
- Yes
- No
Difficulty breathing
- Yes
- No
Radiation treatment
- Yes
- No
Emphysema
- Yes
- No
Rheumatic / Scarlet fever
- Yes
- No
Epilepsy / Convulsions
- Yes
- No
Seizures
- Yes
- No
Leukemia
- Yes
- No
Shingles
- Yes
- No
Angina
- Yes
- No
Sickle cell disease / Traits
- Yes
- No
Frequently Tired
- Yes
- No
Sinus problems
- Yes
- No
Fainting spells
- Yes
- No
Stroke
- Yes
- No
Frequent headaches
- Yes
- No
Thyroid problems
- Yes
- No
Glaucoma
- Yes
- No
Tuberculosis (TB)
- Yes
- No
Hay fever
- Yes
- No
Stomach Troubles / Ulcers
- Yes
- No
Heart attack / Surgery
- Yes
- No
Venereal disease
- Yes
- No
Heart murmur
- Yes
- No
Swollen Ankles
- Yes
- No
Hepatitis / Jaundice
- Yes
- No
Recent Weight Loss
- Yes
- No
Herpes / Fever blisters
- Yes
- No
Respiratory Problems
- Yes
- No
High blood pressure
- Yes
- No
Please list any serious medical condition(s) that you have ever had :
Aspirin
- Yes
- No
Erythromycin
- Yes
- No
Penicillin
- Yes
- No
Barbiturates
- Yes
- No
Jewelry / Metals
- Yes
- No
Sedatives
- Yes
- No
Local anesthetics (eg. novocaine)
- Yes
- No
Codeine
- Yes
- No
Sulfa Drugs
- Yes
- No
Tetracycline
- Yes
- No
Dental anesthetics
- Yes
- No
Latex
- Yes
- No
Other
- Yes
- No
Lodine
- Yes
- No
Please list any other drugs / Materials that you are allergic to :
Insurance Information
Primary Insurance
Dental coverage?
- Yes
- No
Insurance Co. name:
Address :
Street Address City State ZIP Code
Phone :
Group# :
Insured’s name :
Relationship :
Birthday :
MM slash DD slash YYYY
SSN :
Insured’s Employer :
Address:
Street Address City State ZIP Code
Secondary Insurance
Dental coverage?
- Yes
- No
Insurance Co. name:
Address:
Street Address City State ZIP Code
Phone :
Group# :
Insured’s name :
Relationship :
Birthday :
MM slash DD slash YYYY
SSN :
Insured’s Employer :
Insured’s Employer :
Address:
Street Address City State ZIP Code
Payment Is Due In Full At The Time Of Treatment

Unless prior arrangements have been approved.
If this office accepts insurance, I understand that I am responsible for payment of service rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all cost of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.*
If this office accepts insurance, I understand that I am responsible for payment of service rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all cost of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Dental History
Why have you come to the dentist today?
Are you currently in pain?
- Yes
- No
Are your teeth sensitive to sweet or sour liquids / foods?
- Yes
- No
Do you feel pain to any of you teeth?
- Yes
- No
Do you have any sores or lumps in or near your mouth?
- Yes
- No
Have you had any head, neck or jaw injuries?
- Yes
- No
Do you clench or grind your teeth?
- Yes
- No
Have you had any orthodontic work?
- Yes
- No
Have you ever had prolonged bleeding following extractions?
- Yes
- No
Have you ever had instruction on the correct method of brushing your teeth?
- Yes
- No
Have you ever had instructions on the care of your gums?
- Yes
- No
Do you require antibiotics before dental treatment?
- Yes
- No
Your current dental health is :
- Good
- Fair
- Poor
Have you ever had a serious/difficult problem associated with any previous dental work?
- Yes
- No
Do you floss daily?
- Yes
- No
Brush daily?
- Yes
- No
Type of bristles on your toothbrush?
- Hard
- Medium
- Soft
Have you ever had gum treatment?
- Yes
- No
Do your gums ever bleed?
- Yes
- No
Ever Itch?
- Yes
- No
Have you ever had periodontal disease?
- Yes
- No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
- Yes
- No
Are your teeth sensitive to :
- Heat
- Cold
Anything Else?
Do you have any loose teeth?
- Yes
- No
Do you still have wisdom teeth?
- Yes
- No
Would you like fresher breath?
- Yes
- No
Whiter teeth?
- Yes
- No
Are you happy with the way your smile looks?
- Yes
- No
If Not, what would you change?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.*
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.
Signature*
Date
MM slash DD slash YYYY

Spouse Information

Relative or friend not living with you

Medical History

Insurance Information

Payment Is Due In Full At The Time Of Treatment

Dental History