New Patient Form

WELCOME

PLEASE TAKE A FEW MOMENTS TO FILL OUT BOTH SIDES OF THIS FORM.

PATIENT INFORMATION

Today’s Date

Email address

Name

Address

City

State

Zip

Sex

Male Female

Birth Date

Age

SS#

Marital Status

Single Married Divorced Widowed Separated

Home #

Cell #

Work #

Employer

Occupation

Employer Address

In case of emergency, contact:

Relationship

Home #

Cell #

Previous Dentist

Last date of dental exam

INSURANCE

Dental Coverage?

Yes No

Insured’s Name

Birth Date

SS#

Insurance Co.

Group #

Policy #

Insurance Co Address

Insured’s Employer

Employer’s Address

SECONDARY INSURANCE

Insured’s Name

Group #

Policy #

Insurance Co. Name

Insurance Co Address

Who may we thank for referring you

If female, are you pregnant or nursing:

Yes No

Dental History

Please check yes or no to indicate if you have had any of the following:

Bad Breath

Yes No

Jaw pain or tiredness

Yes No

Bleeding Gums

Yes No

Lip or cheek biting

Yes No

Blisters on lips or mouth

Yes No

Loose teeth or broken fillings

Yes No

Chew on one side of mouth

Yes No

Mouth breathing

Yes No

Cigarette, pipe, or cigar smoking

Yes No

Orthodontic treatment

Yes No

Clicking or popping jaw

Yes No

Pain around ear

Yes No

Dry mouth

Yes No

Periodontal treatment

Yes No

Fingernail biting

Yes No

Sensitivity to heat

Yes No

Food collection between teeth

Yes No

Sensitivity to sweets

Yes No

Foreign objects in mouth

Yes No

Sensitivity when biting

Yes No

Grinding Teeth

Yes No

Sores or growths in mouth

Yes No

Gums Swollen or Tender

Yes No

Medical History

Physician’s Name

Date of last visit

Phone

Pharmacy

Phone

Please click yes or no to indicate if you have had any of the following:

Abnormal Bleeding

Yes No

Headaches

Yes No

Pacemaker

Yes No

Alcohol/Drug Abuse

Yes No

Heart Attack

Yes No

Psychiatric care

Yes No

Anemia

Yes No

Heart Murmur

Yes No

Radiation Therapy(cancer)

Yes No

Arthritis

Yes No

Heart Surgery

Yes No

Rheumatic/Scarlet Fever

Yes No

Artificial Bones/joints/Valves

Yes No

Hemophilia

Yes No

Seizures

Yes No

Asthma

Yes No

Hepatitis

Yes No

Shingles

Yes No

Blood Transfusion

Yes No

Herpes/Fever Blisters

Yes No

Sickle Cell Disease/Traits

Yes No

Cancer/Chemotherapy

Yes No

High Blood Pressure

Yes No

Sinus Problems

Yes No

Congenital Heart Defect

Yes No

HIV/Aids

Yes No

Stroke

Yes No

Diabetes

Yes No

Hospitalization

Yes No

Thyroid Problems

Yes No

Difficulty Breathing

Yes No

Joint (artificial joints,screws,pins)

Yes No

Tuberculosis

Yes No

Emphysema

Yes No

Kidney Problems

Yes No

Tumors or Growths

Yes No

Epilepsy

Yes No

Liver Disease

Yes No

Ulcers

Yes No

Fainting or Dizziness

Yes No

Low Blood Pressure

Yes No

Venereal Disease

Yes No

Glaucoma

Yes No

Lupus

Yes No

Please list any serious medical conditions that you have ever had

Are you allergic to any of the following:

Aspirin

Yes No

Erythromycin

Yes No

Penicillin

Yes No

Anesthesia

Yes No

Latex

Yes No

Tetracycline

Yes No

Codeine

Yes No

Metals

Yes No

Other

Yes No

Please list any other drugs/materials allergic to:

Are you taking any prescription /over the counter or herbal supplements/

Have you ever taken Fosamax, any other Bisphosphonates, or Phen-Fen

I understand that the information I have given is correct to the best of my knowledge and will notify office of any changes. I authorize dental staff to perform any necessary dental services for my treatment. If the office accepts my insurance, I understand that the office will file insurance and use my signature on all insurance submissions. I am responsible for payment of services rendered, any co-payments and deductibles that my insurance does not cover at the time of service. I hereby assign payment to the dental office and the release of any information necessary to my Insurance company

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

Date

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