Patient Information Form (Adult)

Full Name

Soc. Sec. No.

Address

City

State

Zip

Home Phone No.

Cell Phone No.

Email address

Age

Date of Birth

Single

Married

Widowed

Separated

Divorced

Patient Employed By

Occupation

Business Address

Business Phone No.

Business Email

Whom may we thank for referring you?

Notify in case of emergency

Home Phone No.

Business Phone No.

Cell Phone No.

Email address

PRIMARY INSURANCE

Person Responsible for Account

Relation to Patient

Soc. Sec. No.

Birthdate

Address (If different from patient)

City

State

Zip code

Home Phone No.

Business Phone No.

Email address

Insurance Company

Home Phone No.

Insurance Mailing Address

Contract No.

Group No.

Subscriber No.

Name of other dependents under this plan

Pharmacy Name

Phone No.

ADDITIONAL INSURANCE

Subscriber Name

Relationship to Patient

Birthdate

Address (If different from patient)

Soc. Sec. No

City

State

Zip Code

Home Phone No.

Cell Phone No.

Email address

Subscriber Employed By

Business Phone No.

Business Email address

Insurance Company

Phone No.

Insurance Mailing Address

Group No.

Subscriber No.

Contract No.

Name of other dependents under this plan

DENTAL HISTORY

What would you like us to do today?

Are you in dental discomfort today?

Former Dentist

Address

Dentist's Email

Phone No.

Date of last dental care

Date of last x-rays

How often do you brush?

Floss?

How do you feel about the appearance of your teeth?

Other information about your dental health or previous treatment

MEDICAL HISTORY

Physician's Name

Phone No.

Date of last visit

If yes, describe

If yes, give approximate dates

Please check all that apply:

Cigarettes

Cigars

Vape

Marijuana

Chew

Other

If Cancer, Please specify type

Date

If yes for Chemo/Radiation Treatments, date of last treatment

Food Allergies? Please list

Auto Immune Disease

What Type?

Other Medical Conditions, Please list

If yes, list all.

Authorization

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered.

I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

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

Payment is due in full at time of treatment, unless prior arrangements have been approved.

Your information will be encrypted.