Adult New Patient Paperwork

1. About You

Today's Date

E-mail Address

Last Name

First Name

I prefer to be called

Birthdate

Age

Social Security Number

Home Address

Apt / Condo #

City

State

Zip

Home #

Cell #

Work #

Employer

Employer's Address

How long there?

Where & when are best times to reach you?

Whom may we Thank for referring you?

Other family members seen by us

Previous / Present Dentist

2. Spouse Information

Last Name

First Name

Employer

Contact #

Social Security Number

Birthdate

Driver's License #

3. Person Responsible for Account

Last Name

First Name

Contact #

Billing Address

Relationship

Social Security Number

Employer

4. Emergency Contact

In the event of an emergency, is there someone who lives near you that we should contact?

Last Name

First Name

Relationship

Cell Phone

Home Phone

Work Phone

5. Insurance Coverage

PRIMARY

Dental Coverage

Yes No

Insurance Co. Name

Insurance Co. Address

Insurance Co. Phone #

Group # (Plan, Local or Policy #)

Insured's Name

Relation

Insured's Birthdate

Insured's ID #

Insured's Employer

SECONDARY

Dental Coverage

Yes No

Insurance Co. Name

Insurance Co. Address

Insurance Co. Phone #

Group # (Plan, Local or Policy #)

Insured's Name

Relation

Insured's Birthdate

Insured's ID #

Insured's Employer

6. Medical History

Do you have a personal physician?

Yes No

Physician's Name

Phone #

Date of Last Visit

Notes on current care or other important Information

Your Current physical health is

Good Fair Poor

Are you taking any prescription / over -the-counter or herbal supplement drugs?

Yes No

Please list each one

Have you ever taken Fosamax, or any other bisphosphonate?

Yes No

Have you ever taken Phen-Fen?

Yes No

If so, when?

Have you been told that you snore or hold your breath while sleeping or wake up gasping for breath?

Yes No

For Women: Are you using a prescribed method of birth control?

Yes No

Are you pregnant?

Yes No

If pregnant, number of weeks

Are you nursing?

Yes No

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

Abnormal Bleeding

Yes No

Alcohol / Drug Abuse

Yes No

Anemia

Yes No

Arthritis

Yes No

Artificial Bones / Joints / Valves

Yes No

Asthma

Yes No

Blood Transfusion

Yes No

Cancer / Chemotherapy

Yes No

Colitis

Yes No

Congenital Heart Defect

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 Attack

Yes No

Heart Murmur

Yes No

Heart Surgery

Yes No

Hemophilia

Yes No

Hepatitis

Yes No

Herpes / Fever Blister

Yes No

High Blood Pressure

Yes No

HIV / AIDS

Yes No

Hospitalized for Any Reason

Yes No

Kidney Problems

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Pacemaker

Yes No

Psychiatric Treatment

Yes No

Radiation Treatment

Yes No

Rheumatic / Scarlet Fever

Yes No

Seizures

Yes No

Shingles

Yes No

Sickle Cell Disease / Traits

Yes No

Sinus Problems

Yes No

Stroke

Yes No

Thyroid Problems

Yes No

Tuberculosis (TB)

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Please list any serious medical condition(s) that you have ever had

Are you allergic to any of the following?

Aspirin

Yes No

Codeine

Yes No

Dental Anesthetics

Yes No

Erythromycin

Yes No

Jewelry

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

7. Dental History

Why have you come to the dentist today?

Do you require antibiotics before dental treatment?

Yes No

Are you currently in pain?

Yes No

Do your gums ever bleed?

Yes No

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

Yes No

Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?

Yes No

Your current dental health is

Good Fair Poor

Do you like your smile?

Yes No

Would you like whiter teeth?

Yes No

Fresh breath?

Yes No

How many times a week do you floss?

a day do you brush?

Type of bristles?

Soft Medium Hard

Do you smoke or use tobacco in any other form?

Yes No

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.

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

Date

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 services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

Signature

Date

Our office is HIPAA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

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