Patient Information

Patient Name

Date of Birth

Address

City

State

Zip

Home Phone No.

Work Phone No.

Alt No.

Social Security No.

Responsible Party Name: (if different from above)

Address: (if different from above)

City

State

Zip

Home Phone No.

Work Phone No.

Alt No.

Emergency Contact Name

Phone No.

INSURANCE INFORMATION

PRIMARY INSURED

Add new row

SECONDARY INSURED

Add new row

Whom may we thank for referring you to our office?

Is there anything you would like to change about your teeth or smile?

For Office Use Only

Brushing:

Manual

Electric (Sonicare Crest Oral B)

Comment

Duration:

30 sec

1 min

2 min

> 2 min

Comment

Flossing:

Regular Floss

Flossers

Picks

Waterpick

Mouthwash

Comment

Last DDS Appointment

Comment

If yes

Vitals: Pulse / Oxygent content / Blood pressure

DNA Appliance/ Nightguard / Sportguard

Isolite Size:

Shade:

PATIENT MEDICAL HISTORY

Your mouth is a integral part of your body. Health problems you may have, or medication you may be taking, could have an important interrelationship with the dentistry you will receive.
Thank you for answering the following questions.

If yes

Are you allergic to any of the following?

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Women: Are you...

If yes

To the best of my knowledge, the questions on this form have been accurately answered. I understand providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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 Patient, Parent or Guardian

Date

Your information will be encrypted.

Patient Information

INSURANCE INFORMATION

PATIENT MEDICAL HISTORY

Women: Are you...

Pikes Peak Dental - Phong H. Nguyen, DDS, PC