New Patient Information Form

Last Name

First Name

Middle

DOB

Address

City

State

Zip Code

Employer

Home Phone

Work Phone

Cell phone

SSN

Spouse Name

General Dentist

Phone

DENTAL INSURANCE INFORMATION

Insured’s name

Insured’s SSN

Insurance Company

Insured's Employer

Plan/Group

Insured's Date of Birth

Preferred Pharmacy name and phone number

EMERGENCY CONTACT

Name

Relationship

Phone

Address

MEDICAL HISTORY

Have you ever been treated for:

Rheumatic Fever

Yes No

Kidney Disease

Yes No

Heart Murmur

Yes No

Bladder Disease

Yes No

Heart disease

Yes No

Arthritis

Yes No

Congenital Heart lesions

Yes No

Artificial Joints Replacement

Yes No

High Blood Pressure

Yes No

Asthma or Hay Fever

Yes No

Stroke

Yes No

Tuberculosis

Yes No

Heart Pacemaker

Yes No

Epilepsy

Yes No

Anemia

Yes No

A.I.D.S/H.I.V.

Yes No

Diabetes

Yes No

Bisphosphonate, Fosamax, Prolia, Xgeva, Reclast etc.

Yes No

Hepatitis

Yes No

Blood Thinners (Coumadin, Plavix, Aspirin etc.)

Yes No

Glaucoma

Yes No

Sinus Infection

Yes No

Have you ever had severe bleeding or other complications following an extraction?

Yes No

Have you ever been on cortisone or steroid therapy?

Yes No

Have you been hospitalized in the past five years?

Yes No

Are you subject to fainting spells?

Yes No

Are you pregnant?

Yes No

Are you allergic to any drugs, medicines, or injections?

Yes No

If Yes, please write down which

Medications

Add more medications

Add Reason

Please add anything you feel is important for the doctor to know:

I do hereby authorize the performance of diagnostic services and dental treatment for the above patient by the dental professionals and the staff of this dental clinic, their assistants, and designees. I further authorize the administration of anesthetics and medications as are deemed necessary. I understand that all diagnostic aids, including radiographs, are the property of the clinic.

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

If this consent is signed by a parent or guardian on behalf the patient, complete the following:

Parent/Guardian name

Relationship to patient

Your information will be encrypted.