New patient Form

Date

Soc. Sec. #

Birthdate

Patient's Name

Home Phone

Address

Cell Phone

City

State

Zip Code

Email address

Employer

Business Phone

Business Address

Occupation

Who should we thank for referring you?

In case of emergency, who should we contact?

Phone

PRIMARY DENTAL INSURANCE

Person Responsible for Account

Relationship to Patient

Birthdate

Soc. Sec. #

Address

Home Phone

City

State

Zip Code

Responsible Party Employed By

Business Phone

Business Address

Occupation

Insurance Company

Ins. Company Address

Subscriber I.D. #

Group #

ADDITIONAL INSURANCE

Insurance Name

Relationship to Patient

Birthdate

Soc. Sec. #

Address

Home Phone

City

State

Zip

Insured Employed By

Business Phone

Insurance Company

Insurance Company Address

Insured Employed By

DENTAL HISTORY

Former Dentist

City

State

Date of Last Dental Visit

Date of Last X-Rays

How Often Do You Floss?

How Often Do You Brush?

MEDICAL HISTORY

Physician's Name

Date of Last Visit

1. Are you currently under medical treatment?

Yes No

2. Have you ever had any serious illnesses or operations?

Yes No

3. Are you currently taking any medication?

Yes No

Please describe

4. Do you smoke?

Yes No

5. Do you use alcohol, cocaine or other drugs?

Yes No

6. Do you wear contact lenses?

Yes No

7. Have you had any allergic reactions to the following:

Local Anesthetics (eg. novocaine)

Penicillin or other Antibiotics

Sulfa Drugs

Barbiturates (sleeping pills)

Sedatives

Iodine

Aspirin

Other

8. (Women Only) Are you:

Pregnant?

Nursing?

Taking birth control pills?

ASSIGNMENT AND RELEASE

I hereby authorize payment directly to

for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

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 of Responsible Party

Date

Your information will be encrypted.

New patient Form

PRIMARY DENTAL INSURANCE

ADDITIONAL INSURANCE

DENTAL HISTORY

MEDICAL HISTORY

ASSIGNMENT AND RELEASE

FAMILY DENTAL CARE OF MILAN