New Patient Form

Patient Information

Date:

SS#

Last Name:

First Name:

Middle Initial:

Address:

City:

State:

Zip:

Email:

Birthdate:

Age:

Sex:

Male Female

Marital Status:

Married Widowed Single Minor Separated Divorced Partnered

If Partnered, How many years?

Patient Employer/School:

Occupation:

Employer/School Phone:

Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account?

Relationship to Patient:

Insurance Co.:

Group #:

Is patient covered by additional insurance?

Yes No

Subscriber's Name:

Birthdate:

SS #:

Relationship to Patient:

Insurance Co.:

Group #:

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with (Please state the name of Insurance Company(ies) below)

and assign directly to Dr. (Please state the name of the Dr. below), 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 dentist 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 from the date signed below.

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.

Signature of Patient, Parent, Guardian or Personal Representative:

Please print name of Patient, Parent, Guardian or Personal Representative:

Date:

Relationship to Patient:

Phone Numbers

Main Contact #:

Alternate contact #:

Best time and place to reach you:

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

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Dental History

Reason for today's visit:

Former Dentist:

City/State:

Date of Last Dental Visit:

Date of Last Dental X-rays:

Please choose on "Yes or No" to indicate if you had any of the following:

Bad Breath

Yes No

Bleeding Gums

Yes No

Blisters on lips or mouth

Yes No

Burning sensation on tongue

Yes No

Chew on one side of mouth

Yes No

Cigarette, pipe or cigar smoking

Yes No

Clicking or Popping Jaw

Yes No

Dry Mouth

Yes No

Fingernail Biting

Yes No

Food collection between the teeth

Yes No

Foreign Objects

Yes No

Grinding Teeth

Yes No

Gums swollen or tender

Yes No

Jaw pain or Tiredness

Yes No

Lip or cheek biting

Yes No

Loose teeth or broken fillings

Yes No

Mouth Breathing

Yes No

Mouth Pain, Brushing

Yes No

Orthodontic Treatment

Yes No

Pain around ear

Yes No

Periodontal Treatment

Yes No

Sensitivity to cold

Yes No

Sensitivity to heat

Yes No

Sensitivity to sweets

Yes No

Sensitivity when biting

Yes No

Sores or growths in your mouth

Yes No

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 collective drugs collectively referred to as "fen-phen?" These include combinations of Ionmin, Adipex, Fastin (Brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Yes No

Please choose on "Yes or No" to indicate if you had any of the following:

AIDS/HIV

Yes No

Anemia

Yes No

Arthritis, Rheumatism

Yes No

Artificial Heart Valves

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Back problems

Yes No

Blooding abnormally with extractions and surgery

Yes No

Blood disease

Yes No

Cancer

Yes No

Chemical Dependency

Yes No

Chemotherapy

Yes No

Circulatory Problems

Yes No

Congenital Heart Lesions

Yes No

Cortisone Treatments

Yes No

Cough, Persistent or Bloody

Yes No

Diabetes

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fainting or Dizziness

Yes No

Glaucoma

Yes No

Headaches

Yes No

Heart Murmur

Yes No

Heart Problems

Yes No

Hepatitis

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

Jaundice

Yes No

Jaw Pain

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Nervous Problems

Yes No

Pacemaker

Yes No

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Respiratory Disease

Yes No

Rheumatic Fever

Yes No

Scarlet Fever

Yes No

Shortness of Breath

Yes No

Sinus Trouble

Yes No

Skin Rash

Yes No

Special Diet

Yes No

Stroke

Yes No

Swollen Feet and Ankles

Yes No

Swollen Neck Glands

Yes No

Thyroid Problems

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumor or Growth on Head or Neck

Yes No

Ulcer

Yes No

Venereal Disease

Yes No

Weight Loss, Unexplained

Yes No

If you have Hepatitis, please specify what type of hepatits do you have below:

Do you wear Contact Lenses?

Yes No

For Women Only:

Are you Pregnant?

Yes No

Are you Nursing?

Yes No

Taking Birth Control Pills?

Yes No

Due Date:

Medications

List any medications you are currently taking and the correlating diagnosis:

Pharmacy Name:

Phone #:

Allergies

Aspirin

Barbiturates

Codeine

Iodine

Latex

Local anesthetic

Penicillin

Sulfa

Other

If other, please specify:

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