Welcome Page

1. About You

Today's Date

File #

Patient Last Name

First Name

Sex

What you prefer to be called?

Birthdate

Age

SS #

Mailing Address

City

State

Zip

Home Phone #

Work Phone #

Cell Phone #

E-mail Address

Referred By

Employer

How Long?

Employer's Address

City

State

Zip

Occupation

Status

Spouse's Name

Do you have children?

If yes, How Many?

2. Insurance Info

Primary Dental Insurance

Co. Name

Address

City

State

Zip

Phone #

Insured's ID #

Group# (Plan, Local, or Policy#)

lnsured's Name

Relation

Date of Birth

Insured's Employer

Secondary Dental Insurance

Co. Name

Address

City

State

Zip

Phone #

Insured's ID #

Group# (Plan, Local, or Policy#)

lnsured's Name

Relation

Date of Birth

Insured's Employer

3. Account Info

Person ultimately responsible for account

Name

Relation

Billing Address

City

State

Zip

SS #

Drivers License #

Work Phone #

Payment method

Enter Card #

Expiration Date / Year

Credit Card - Enter card # above

I hereby authorize the 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 (if offered at this office).

Disclaimer: By typing in your initials, you are signing this application electronically. You agree your electronic signature/initials are the legal equivalent of your manual signature/initials on this application.

Initial

4. In Event of Emergency

Whom should we contact?

Relation

Home Phone #

Work Phone #

Cell Phone #

Who is your Medical Doctor?

Medical Doctor's Phone #

5. Dental Information

Reason for today's visit

Exam Emergency Consultation

Are you in pain?

No Yes

How Long?

If Other, Please specify

Do you require pre-medication?

Yes No Don't know

Previous Dentist

Phone #

Last Dental exam

Last Dental X-rays

Times a day you brush?

Times a week you floss?

What type of tooth brush bristles do you use?

Soft Medium Hard

How would you rate your smile?

6. Medical History

What medications are taking?

Nerve pills

Pain Killers (including aspirin)

Muscle relaxers

Stimulants

Blood Thinners

Tranquilizers

Insulin

Meds for Osteoporosis

Other(s)

If Other, Please specify

Have you ever taken: Bisphosphonates (ex. Aredia/Fosamax)

Yes No

Have you ever taken: Phen-fen/Redux

Yes No

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

Dental Anesthetics

Foods

Others

Please List Foods:

Please List Others:

Do you use tobacco?

If yes, How used?

How much?

How long?

Please rate your general health from 1-10

Do you wear contact lenses?

For Women:

Are you taking Birth Control pills?

How many children have you had?

Are you Pregnant?

No Yes

If yes, How long?

Are you nursing?

Yes No

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 arrangements have been made with the business manager. If the account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges, and any other expenses incurred in collecting your account.
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 and understand it is my responsibility to inform this office of any changes to the information I have provided.

Initials

I acknowledge that I have received a copy of the Summary of Privacy Notice.

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 or Guardian

Spouse

Your information will be encrypted.