Patient Information Form

Today's Date

Last Name

First Name

What you prefer to be called

Birthdate

Age

SS#

Mailing Address

City

State

Zip

Home Phone #

Work Phone #

Cell Phone #

Email address

How you prefer to be contacted

Referred By

Employer

How long?

Employer's Address

City

State

Zip

Occupation

Spouse's Name

How many?

Person Ultimately Responsible for Account

Name

Relation

Billing Address

City

State

Zip

SS#

Drivers License #

Work Phone #

Other Phone #

I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company.

Primary Dental Insurance

Add Secondary Insurance

Emergency Contact

Contact Person

Relation

Home Phone #

Work Phone #

Cell Phone #

Medical Doctor

Med. Dr. Phone #

Dental Information

How Long / Describe

If other, please specify

Have you ever been told to premedicate with antibiotics before a dental appointments?

Yes No Don't know

Previous Dentist

Address

Phone #

Date of Last Dental Exam

Date of Last Dental X-rays

Times a day you brush?

Times a week you floss?

Medical History

What medications are you taking?

Nerve pills

Pain Killers (including aspirin)

Muscle Relaxers

Stimulants

Blood Thinners

Tranquilizers

Insulin

Meds for Osteoporosis

Other(s)

If other, please indiciate

Please list any other surgeries or medical conditions you have, or ever had

Are you allergic to any of the following?

Latex

Penicillin/Amoxicillin

Tetracycline

Aspirin

Sulfa

Codeine

Dental Anesthetics

Foods

Other

If food, Please indicate

If other, Please indicate

Please describe your reaction

How used?

How much?

How long?

Please rate your general health from 1-10

For Women

How far along?

Consent / Treatment Authorization

We invite you to discuss with us any questions regarding our services. THe best dental health services are based on a friendly, mutual understanding between provider and patient.
Our policy requires payment in full for all services rendered at the time of visit, unless other arragements have been made.
We routinely take diagnostic records every 12 months. We reserve the right to refuse treatment if these x-rays are refused over a 3-year period.
Appointment times are scheduled only for you. We respect your time, and we ask that you respect ours. Therefore, any 3 failed appointments within a one-year period, or 3 consecutive failed appointments, are considered a reason for dismissal from our practice. A failed appointment is a cancellation with less than a 24-hour notice, or a failure to show up for a scheduled appointment.
I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
I understand the above information and guarantee this form was completed correctly to the best of my knowledge.I understand it is my responsibility to inform this office of any changes to the information I have provided.

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

Adult Patient

Parent / Guardian

Yearly Updates

I have reviewed this document and certify that it is 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.

Signature

Date

Your information will be encrypted.