New Patient Forms

Last Name

Middle Initial

First Name

Prefix

Mr. Mrs. Ms.

Address

City

State

Zip

Cell Phone #

Home Phone #

Birthdate

Soc. Sec. No.

Referred By

Person Responsible for Payment

Same as patient

Last Name

Middle Initial

First Name

Mailing Address

City

State

Zip

D.O.B.

Soc. Sec. No.

Cell Phone #

Employer's Name

Address

City

State

Zip

Employer's Phone

Primary Dental Insurance

Relationship with Patient

Insurance Company

Phone #:

Subscriber Last Name

Subscriber Middle Initial

Subscriber First Name

Subscriber ID #

Social Security #

Subscriber D.O.B.

Address

City

State

Zip

Phone

Plan ID

Group No.

Is coverage through employer?

Yes No

Secondary Dental Insurance

Subscriber Last Name

Subscriber Middile Initial

Subscriber First Name

Subscriber ID #

Social Security #

Subscriber D.O.B.

Address

City

State

Zip

Phone

Is coverage through an employer?

Yes No

Person to Contact in Case of Emergency

Name

Phone #

I/We Authorize the release of any medical information necessary to process my claim. I/We request that any payment of insurance benefits be paid to Aziz A. Majid DMD, MSD, PC. I/We also understand that if for any reason, the insurance company doesn't pay for services, or if they only provide partial payment that I/We will be responsible for the same. I/We agree 1 1/2 % interest per month on any outstanding balance and attorney Fees.

Before treatment can begin, this agreement must be signed by the dental insurance holder as the responsible person, along with the patient, in the event that patient is not also the dental insurance contract holder.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Responsible Person's Signature

Date

PATIENT MEDICAL HISTORY

Has there been any change in your general health in the past year?

Yes No

If yes, explain:

Have you been hospitalized in past two years?

Yes No

If yes, explain:

Physician Name

Physician Phone

Pharmacy

Pharmacy Phone

Check any of the following that you are taking or have taken:

Cortisone Drugs

Yes No

Anticoagulants

Yes No

Tranquilizers

Yes No

Steroids

Yes No

BloodThinners

Yes No

Sedatives

Yes No

Are you taking any other medication?

Yes No

If yes, explain:

Sex

If female, please answer the following:

Are you taking Birth Control Pills?

Yes No

Are you pregnant?

Yes No

If yes, When

Are you nursing?

Yes No

Please answer the following:

Doyousmoke or use tobacco?

Yes No

Height

Weight

For Office Use Only

Heart Rate

Conditions

Abnormal Bleeding

Yes No

Alcohol Abuse

Yes No

Allergies

Yes No

Anemia

Yes No

Angina Pectoris

Yes No

Arthritis

Yes No

Artificial Bones

Yes No

Artificial Heart Valve

Yes No

Asthma

Yes No

Blood Transfusion

Yes No

Cancer- Chemotherapy

Yes No

Colitis

Yes No

Congenital Heart Defect

Yes No

Cosmetic Surgery

Yes No

Diabetes

Yes No

Difficulty Breathing

Yes No

Drug Abuse

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fainting Spells

Yes No

Fever Blisters

Yes No

Frequent Headaches

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack

Yes No

Heart Surgery

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B

Yes No

High Blood Pressure

Yes No

HIV+ AIDS

Yes No

Kidney Problems

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Pace Maker

Yes No

Pneumocystius

Yes No

Psychiatric Problems

Yes No

Radiation Therapy

Yes No

Rheumatic Fever

Yes No

Seizures

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Problems

Yes No

Stroke

Yes No

Thyroid Problems

Yes No

Tuberculosis

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Yellow Jaundice

Yes No

Allergies

Aspirin

Yes No

Codeine

Yes No

Dental Anesthetics

Yes No

Erythromycin

Yes No

Jewelry

Yes No

Latex

Yes No

Metals

Yes No

Penicillin

Yes No

Tetracycline

Yes No

Other

Is there any disease, condition, or problem that you think this office should know about that is not covered above?

Yes No

If yes, please describe:

DENTAL HISTORY

Do you have any present dental complaints?

Yes No

If yes, explain:

How long has it been since you have been to a dentist?

What was done then?

Did you have X-rays taken?

Yes No

Date of last cleaning

Have you been instructed in caring for your gums?

Yes No

Reason for today's visit

Former dentist

Date of last dental visit

Date of last cleaning

Did you have X-rays taken?

Yes No

Do you have fear of dentistry being done?

Yes No

If yes, why?

Bad breath

Yes No

Bad taste

Yes No

Bleeding gums

Yes No

Blisters on tip of mouth

Yes No

Burning sensation on tongue

Yes No

Chew on one side of mouth

Yes No

Smoking

Yes No

Dark teeth

Yes No

Grinding teeth

Yes No

Jaw pain

Yes No

Loose or broken teeth

Yes No

Periodontal treatment

Yes No

Sensitivity to hot & cold

Yes No

Sores or growth in your mouth

Yes No

Food collecting between teeth

Yes No

Dry mouth

Yes No

Gums swollen or tender

Yes No

Root Canal Treatment

Yes No

What would you like to change the most in the appearance of your teeth?

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