Adult Patient Information

Date

SS/HIC/Patient ID #

Birthdate

Patient Name

Age

If partnered, how many years?

Home Address

City

State

Zip

Email address

Patient Employer / School

Occupation

Employer / School Address

Employer / School Phone

Spouse's Name

Birthdate

SS #

Spouse's Employer

Who may we thank for referring you?

DENTAL INSURANCE

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Subscriber's Name

Birthdate

SS #

Relationship to Patient

Insurance Co.

Group #

Assignment and Release

I certify that I, and/or my dependent(s) have insurance coverage with

and assign directly to Dr.

all insurance benefits, if any, 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 use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

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.

Signature of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

Date

PHONE NUMBERS

Phone

Work

Ext.

Alt. Phone

Spouse's Work

Best time and place to reach you

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

Name

Relationship

Phone

Work Phone

DENTAL HISTORY

Reason for today's visit

Former Dentist

City

State

Date of last dental visit

Date of last dental X-rays

How often do you floss?

How often do you brush?

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.

Yes No

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Yes No

If Hepatitis, Type:

If other, Please specify

Do you wear contact lenses?

Yes No

(Women) Are you pregnant?

Yes No

If yes, Due date?

Are you nursing?

Yes No

Taking birth control pills?

Yes No

Medications

List any medications you are currently taking and the correlating diagnosis

Pharmacy Name

Phone

Allergies

Aspirin

Barbiturates (Sleeping pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

If other, Please specify

Patient's Signature

Date

UPDATES (to to filled in at future appointments )

Has there been any change in your health since your last dental appointment?

Yes No

For what conditions?

Are you taking any new medications?

Yes No

If so, what?

Patient's Signature

Date

Doctor's Signature

Date

Acknowledgement of Receipt of Notice of Privacy Practices

You may refuse to Sign This Acknowledgement

have received a copy of this office's Notice of Privacy Practices.

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

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

If other, Please specify

Your information will be encrypted.