Patient Forms

1. Patient Information

Patient:

Date:

Address

City

State

Zip

I prefer to be called:

Mr. Mrs. Miss

Other:

Birthdate:

Gender:

F M

Age:

Marital Status:

Single Married Widowed Separated Divorced

Patient SSN#:

If patient is a minor, give parent's or guardian's name:

Occupation:

Employer:

Spouse's Name:

Spouse's Occupation:

Spouse's Employer:

Whom may we thank for referring you?

2. Phone Numbers

Home Phone No.:

Cell Phone No.:

Work:

Ext.:

Spouse's Work:

E-Mail:

Best time and place to reach you.:

Family Physician's Name:

Physician's Phone No.:

IN CASE OF EMERGENCY CONTACT (Specify someone who does not live in your household.)

Name:

Relationship:

Home Phone:

Work Phone:

3. Dental Insurance

Subscriber/Policy Holder

Subscriber SSN#:

Subscriber Birthdate:

Relationship to patient:

Insurance Co.:

Group No.:

Insurance Co. Phone Number:

ID Number:

4. Assignment and Release

I certify that I (or my dependent) have insurance coverage as indicated and assign directly to this office all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by Insurance. I authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Responsible Party Signature

Relationship to Minor (if Applicable)

Date:

In order to ensure your maximum oral health and allow us to prescribe the proper medications, it is very important that we know all medical and dental information about you. Please check every box on this form, even if the answer is "N/A" (not applicable). This information will be kept in the strictest confidence.

You also should know that changes in other parts of your body may affect the oral cavity and what dental treatment can be done, even if they seem unconnected. Cardiac (heart) problems, artificial joints and diabetes are just some examples.

Will you please inform the dentist or the staff at the beginning of each new office visit if your medical or dental conditions have changes since we last saw you?

Yes No

Thank You

1. Dental History

Reason for today's visit:

Former Dentist:

Date of last dental visit:

Date of last dental x-rays:

Mark "Yes" or "No" to indicate if you presently or previously had any of the following.

Bad Breath

Yes No

Bite your lips or cheeks regularly

Yes No

Bleeding Gums

Yes No

Blisters on lips or mouth

Yes No

Chew on one side of mouth

Yes No

Dry mouth

Yes No

Food collection between the teeth

Yes No

Grinding teeth

Yes No

Gums swollen or tender

Yes No

Jaw pain or tiredness

Yes No

Mouth breathing

Yes No

Orthodontic treatment

Yes No

Pain around ear

Yes No

Periodontal (gum) treatment

Yes No

Sensitivity to cold

Yes No

Sensitivity to hot

Yes No

Have you experienced:

Clicking or popping of the jaw?

Yes No

Pain? (joint, ear, side of face)

Yes No

Difficulty in opening or closing the mouth

Yes No

How often do you floss

How often do you brush

Do you require antibiotics before denial treatment

Yes No

Are you currently in pain

Yes No

Have you ever had a serious/difficult problem associated with any previous dental work

Yes No

Do you like your smile?

Yes No

Do you feel nervous about having dental treatment

Yes No

Have you ever had a bad experience in a dental office?

Yes No

If yes, please describe

Is there anything else about having dental treatment that you would like us to know?

2. Medical History

Your current physical health is:

Good Fair Poor

Are you currently under the care of a physician?

Yes No

Please explain

Are you taking any prescriptions/over the counter drugs?

Yes No

Please list each one:

Do you smoke or use tobacco in any other forms

Yes No

For Women

Are you taking birth control pills?

Yes No

Are you pregnant?

Yes No

Are you nursing?

Yes No

Do you have or have you ever had any of the following diseases or medical problems?

Abnormal Bleeding

Yes No

Alcohol/Drug Abuse

Yes No

Alzheimer's Disease

Yes No

Anemia

Yes No

Arthritis

Yes No

Artificial Bones/Joints/Valves

Yes No

Asthma

Yes No

Blood Transfusion

Yes No

Bruise Easily

Yes No

Cancer/Chemotherapy

Yes No

Colitis

Yes No

Diabetes

Yes No

Difficulty Breathing

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fainting Spells

Yes No

Frequent Headaches

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Problems

Yes No

Heart Murmur

Yes No

Hemophilia

Yes No

Hepatitis

Yes No

Herpes/Fever Blisters

Yes No

High Blood Pressure

Yes No

HIV+ / AIDS

Yes No

Hospitalized for any reason

Yes No

Joint Replacement

Yes No

Kidney Problems

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Nervous/Anxious

Yes No

Pacemaker

Yes No

Psychiatric / Psychological Care

Yes No

Radiation Treatment

Yes No

Rheumatic / Scarlet Fever

Yes No

Seizures

Yes No

Sinus Problems

Yes No

Stroke

Yes No

Thyroid Problems

Yes No

Tuberculosis (TB)

Yes No

Tumors or Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Do you have or have you had any disease, condition, or problem not listed?

Yes No

Are you allergic to any of the following?

Aspirin

Yes No

Codeine

Yes No

Dental Anesthetics

Yes No

Latex

Yes No

Metals

Yes No

Penicillin

Yes No

Tetracycline

Yes No

Please list any other drugs/materials that you are allergic to:

3. Certification

I certify that the answers given are correct to the best of my knowledge.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name/Signature:

Date:

Your information will be encrypted.