New Patient Form

Patient Information

Patient Name

Today’s Date

What you prefer to be called

Birthdate

Sex

Male Female Other

SSN #

Driver’s License #

Mailing Address

Phone

Alt. Phone

Email Address

Referred By

Employer

Occupation

Marital Status

# of Children

Dental Insurance Information

Primary Insurance

Company Name

Phone Number

Group #

ID #

Insured’s Name

Insured’s Birthdate

Relation

Secondary Insurance

Company Name

Phone Number

ID #

Received Welcome Letter, Consent, & HIPAA Forms

EMERGENCY CONTACT

Whom Shall We Contact

Relation

Phone #

Your Medical Doctor

Doctor’s Phone #

ASSIGNMENT OF BENEFITS

I hereby authorize assignments of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for my balance not paid by my insurance company.

Dental Health History Information

Reason for Today’s Visit:

Emergency visit

Comprehensive exam

Consultation

Cleaning

Other

Please indicate any of the following problems that you are having:

Discomfort, clicking or popping in the jaw

Yes No

Broken teeth and/or lost fillings

Yes No

Bad breath

Yes No

Blisters/sores in or around the mouth

Yes No

Ringing in the ears

Yes No

Teeth grinding

Yes No

Red, swollen or bleeding gums

Yes No

Stained teeth

Yes No

Oral and Pharyngeal Cancer Checklist

Check all that apply:

soreness or a feeling that something is caught in the throat

a lump or thickening in the oral soft tissues

numbness of the tongue or other areas of the mouth

difficulty moving the jaw or tongue

difficulty chewing or swallowing

hoarseness

ear pain

swelling of the jaw that causes dentures to fit poorly or become uncomfortable

Last Dental Exam and Dental X-Rays

Last Dental Cleaning

Times a Day you brush

Times a Day you floss

Soft Bristle Brush

Yes No

Do you have any questions or concerns about previous dental work rendered or recommended?

Yes No

Medical History and Information

What medications and/or vitamin supplements are you currently taking?

None

Pain Medication

Antibiotics

Aspirin

Blood Thinners

Insulin

Inhaler

Other

If other, please specify.

List allergies dental or non-dental related:

None

Penicillin/Amoxicillin

Codeine

Latex

Food

Other

If other, please specify.

Do you require antibiotic prophylaxis prior to dental appointments? (certain joint replacements, heart conditions/surgeries and cancer treatment) Medical clearance advised.

Yes No

Do you use tobacco?

Yes No

How long?

How often?

For Women:

Are you pregnant?

Yes No

Are you nursing?

Yes No

Are you taking hormonal replacements?

Yes No

Do you have or have you had any of the following diseases, medical conditions or procedures answer YES or NO to all:

High/Low Blood Pressure

Yes No

Cancer/Tumor Growth

Yes No

Leukemia

Yes No

Heart Attack/Stroke

Yes No

Chemotherapy/Radiation

Yes No

Joint Replacement

Yes No

Rods/Pins

Yes No

Scarlet Fever

Yes No

Heart Surgery/Pacemaker/Stent

Yes No

Mitral Valve Prolapse

Yes No

Hepatitis

Yes No

Rheumatic Fever

Yes No

Congestive Heart Failure

Yes No

Congenital Heart Defect

Yes No

Breast Surgeries

Yes No

Covid-19

Yes No

Diabetes/Hypoglycemia

Yes No

Blood/Bone Marrow Transfusion

Yes No

Tuberculosis

Yes No

Seizures/Epilepsy

Yes No

Heart Disease/Angina

Yes No

HIV/AIDS/ARC

Yes No

Shingles

Yes No

Arthritis/Gout

Yes No

GI Problems/Ulcers

Yes No

Emphysema/Asthma

Yes No

Jaw Pain/TMJ

Yes No

Bruise Easily

Yes No

Severe/Frequent Headaches

Yes No

Dizziness/Fainting

Yes No

Chest Pains

Yes No

Lung Disease

Yes No

Respiratory Problems

Yes No

Back/Neck Problems

Yes No

Allergies

Yes No

Thyroid Problems

Yes No

Psychiatric Problems

Yes No

Alcohol/Drug Abuse

Yes No

Nervousness

Yes No

Sinus Problems

Yes No

Cosmetic Surgery

Yes No

Eating Disorder

Yes No

Sleep Apnea

Yes No

Dental Anxiety

Yes No

Liver Problems

Yes No

Kidney Problems

Yes No

Organ Transplant

Yes No

Lupus

Yes No

Office and Patient Relationship

We are here to discuss any questions or concerns regarding our services. Successful treatment works best if there is a mutual understanding between the provider, staff and the patient.
It is important that you understand and agree to all treatment rendered understanding that treatment plans can change. When treatment changes you will be made aware prior to procedures being done.
I authorize the staff and the provider to perform any necessary services needed during diagnosis and treatment. I also authorize the release of any information needed to process insurance claims.
It is important that you understand all treatment rendered payment in full for all services rendered at the time of visit, unless other financial arrangements have been made with the business manager. If 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, collections agency fees, interest charges and any other expenses incurred in collecting your debt.
I understand that if my treatment is beyond the scope of this office, I will be referred to the appropriate specialist that the provider recommends and my records would be forwarded to the specialist.
I understand the above information and guarantee this form was completed accurately to the best of my knowledge and I understand it’s my responsibility to inform the office of any changes to the information I provided.

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

Patient or Parent/Guardian

Date

Your information will be encrypted.