Patient Information Form

Patient's Name

Date of Birth

Preferred Name

Address

City

State

Zip

Social Security Number

Home Phone

Work Phone

Cell Phone

Email address

Employer/School

Employer/School Phone

Employer/School Address

City

State

Zip

Spouse or Parent's Name

Birthdate

Employer

Work Phone

Whom may we thank for referring you

General Dentist

Emergency Contact

Phone Number

RESPONSIBLE PARTY

Name of Person Responsible for Account (Must be Present to sign)

Relation to patient

Address

Home Phone

Birthdate

Employer

Work Phone

Cell Phone

DENTAL INSURANCE INFORMATION

Insurance Company

Phone Number

Subscriber ID

Subscriber's Social

Group Number

Subscriber's Name

Birth Date

Relationship to Patient

SECONDARY DENTAL INSURANCE INFORMATION

Insurance Company

Phone Number

Subscriber ID

Subscriber's Social

Group Number

Subscriber's Name

Birth Date

Relationship to Patient

MEDICAL INSURANCE INFORMATION

Add new row

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/Guardian/Responsible Party

Date

MEDICAL HISTORY FORM

Name

Date of Birth

Height

Weight

For the following questions, answer yes or no. whichever applies Your answers are for our records only and will be kept confidential.

Are you under a physicians care?

Yes No

What For?

Please list ALL medications you are currently taking (Include any over-the-counter AND prescription medication

Family Physician

Phone Number

Do you need to be pre-medicated with an antibiotic for any reason?

If other, Please specify

If Other, Please specify

Have you had any serious trouble associated with previous dental treatment?

Yes No

If so, Please Explain

Do you have any other condition or disease you think the doctor should know about?

Yes No

If so, Please Explain

Do you smoke or chew tobacco?

Yes No

If yes, How much?

Is there past history of alcohol or chemical dependency or emotional disorder the may affect the care we provide?

Yes No

Are you wearing contact lenses?

Yes No

WOMEN

Are you pregnant or trying to become pregnant

Yes No

Do you have problems associated with your menstrual period?

Yes No

Are you nursing?

Yes No

Are you taking birth control?

Yes No

I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I understand it is my responsibility to fill out the form correctly and completely.

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.

Patient's Signature

Date

Doctor's Signature

Date

Assistant's Signature

Date

Your information will be encrypted.

Patient Information Form

RESPONSIBLE PARTY

DENTAL INSURANCE INFORMATION

SECONDARY DENTAL INSURANCE INFORMATION

MEDICAL INSURANCE INFORMATION

MEDICAL HISTORY FORM

WOMEN

NASHVILLE ORAL SURGERY