Patient Information Form

About You

Date

Email address

Last Name

First Name

I prefer to be called

Birthdate

Age

SS #

Home Address

City

State

Zip

Home #

Cell #

Wk #

Ext.

DL #

Employer

Employer's Address

How long there?

Occupation

Where & when are best times to reach you?

Whom may we Thank for referring you?

Other family members seen by us

Previous / Present Dentist

Last Visit Date

Spouse Information

His / Her Name

Employer

Contact #

Ext.

SS #

Birthdate

Driver's License #

Person Responsible for Account

Contact #

Billing Address

Relation

SS #

Employer

DL #

Insurance Coverage

Add Secondary Insurance

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

His / Her Name

Relation

Wk #

Hm #

Medical History

Do you have a personal physician?

Yes No

Physician's Name

Phone #

Date of last visit

Are you currently under the care of a physician?

Yes No

Please explain

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 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

Week #

Are you nursing?

Yes No

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

Are you allergic to any of the following?

Aspirin

Codeine

Dental Anesthetics

Erythromycin

Jewelry

Latex

Metals

Penicillin

Tetracycline

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

Dental History

Why have you come to the dentist today?

Do you required 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 ever experienced pain / discomfort in your jaw joint (TMJ / TMDJ?)

Yes No

Your current dental health is

Good Fair Poor

Do you like your smile?

Yes No

Would you like white teeth?

Yes No

Fresher breath?

Yes No

How many times a week do you floss?

How many times 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.

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

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

OFFICE USE ONLY

I verbally reviewed the medical / dental information above with the patient named herein.

Date

Doctor's Comments

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