Patient Information Form

We are pleased to welcome you to our office. Please take a few minutes to fill out this form as completely as you can. If you have any questions we'll be glad to help you.

Patient's Name

Preferred Name

Birthdate

SS #

Work Phone

Wireless Phone

Wireless Carrier

Email address

Occupation

Employer

Preferred Contact Method

Home Phone

Work Phone

Wireless Phone

Preferred Contact method for Confirmations

Home Phone

Work Phone

Wireless Phone

Preferred Contact method for Recall

Home Phone

Work Phone

Wireless Phone

Student Status if Dependent over 19 (for ins)

Nonstudent

Full-TIme

Part-Time

How did you hear about us?

If someone referred you here, please write down their name so we can thank them.

ADDRESS AND HOME PHONE

Check box if same for entire family

Address

Address 2

City

State

Zip

Home Phone

INSURANCE POLICY 1

Your relationship to Subscriber

Self

Spouse

Child

Subscriber Name

Subscriber ID #

Insurance Company

Home Phone

Employer

Group Name

Group #

Please present insurance card to receptionist.

INSURANCE POLICY 2

Your relationship to Subscriber

Self

Spouse

Child

Subscriber Name

Subscriber ID #

Insurance Company

Home Phone

Employer

Group Name

Group #

Comments

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

MEDICAL HISTORY FOR NEW PATIENT

Patient's Name

Date of Birth

Name of Medical Doctor

City

State

Emergency Contact

Phone

Relationship

List all medications that you are now taking

Are you allergic to any of the following?

Anesthetic

Aspirin

Codeine

Ibuprofen

Iodine

Latex

Penicillin

Sulfa

Tobacco use? if so, what kind and how much?

Unusual reaction to dental injections?

Reason for today's visit

Are you in pain?

How many ounces of water do you drink a day?

What is your BMI (Body Mass Index)?

What percentage of your diet contains vegetables and fruits?

Do you grind your teeth at night?

Have you had a root canal or endodontic therapy?

Have you ever had cracked teeth?

New Patients:

Do you a Panoramic X-ray or Full Mouth X-rays that are less than 5 years old?

Do you have BiteWing X-rays that are less than 1 year old?

Name of former dentist

City

State

Date of last cleaning and exam

Signature

Date

Your information will be encrypted.