Adult's New Patient Information

Patient

Date

SS/HIC/ Patient ID No.

Address

City

State

Zip

Email address

Age

Date of Birth

Married

Separated

Widowed

Divorced

Single

Minor

Partnered

Occupation

Patient School / Address

Employer School / Address

Employer Phone No.

Spouse's Name

Birthdate

SS No.

Spouse's Employer

Who may we thank for referring you

DENTAL INSURANCE

Add new row

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

Name of Insurance / Company

and assign directly to Dr.

All insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year fro the data signed below.

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, Guardian or Personal Representative

Relationship to Patient

Date

PHONE NUMBERS

Home Phone No.

Work Phone No.

Cell Phone No.

Spouse's Work

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT (Specify someone whos not live in your household)

Name

Relationship

Home Phone No.

Work Phone No.

DENTAL HISTORY

Reason for today's visit

Former dentist

City / State

How often do you floss?

How often do you brush?

HEALTH HISTORY

Physician's Name

Date of last visit

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

WOMEN:

Due date

MEDICATIONS

list any medications you are currently taking and the correlating diagnosis

Pharmacy Name

Phone No.

ALLERGIES

Aspirin

Barbiturates (Sleeping pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

If other, please specify

Signature of Parent/Guardian

Date

Your information will be encrypted.