Patient Information Form

Last Name:

First Name:

Middle Initial:

Preferred Name:

Date:

Marital Status:

Birthdate:

SSN #:

Driver's License #:

Email:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Ext:

Best time to call:

Fax:

Mobile Phone:

Other:

Referral Information

Name of person, office or other source referring you to our practice:

Spouse or Responsible Party Information

Last Name:

First Name:

Middle Initial:

Preferred Name:

Date:

Marital Status:

Birthdate:

SSN #:

Driver's License #:

Email:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Ext:

Best time to call:

Fax:

Mobile Phone:

Other:

Employment Information

The following is for:

The Patient The person responsible for the payment

Employer Name:

Employer's Address:

City:

State:

Zip:

Insurance Information

Primary Insurance

Last Name of Insured:

First Name:

MI:

Insured's Birth Date:

ID #:

Group #:

Address:

City:

State:

Zip:

Insured's Employer Name:

Employer's Address:

City:

State:

Zip:

Patient's relationship to insured:

Self Spouse Child Other

Insurance Plan Name:

Insurance Plan Address:

City:

State:

Zip:

Secondary

Last Name of Insured:

Short text field

Insured's Birth Date:

ID #:

Group #:

Address:

City:

State:

Zip:

Insured's Employer Name:

Employer's Address:

City:

State:

Zip:

Insurance Plan Name:

Insurance Plan Address:

City:

State:

Zip:

Patient's relationship to insured:

Self Spouse Child Other

Other Information

Date of Last Dental Visit:

Emergency Contact Name:

Emergency Contact Number:

Please check Yes or No for the following:

Heart Condition:

Yes No

If yes, explain:

Heart Murmur:

Yes No

If yes, what type?

High Blood Pressure

Yes No

Low Blood Pressure

Yes No

Circulatory Problems:

Yes No

Excessive Bleeding Concern

Yes No

If yes, explain

Auto Immune Disorder

Yes No

If yes, explain

Artificial Valves, Joints or other Prosthetis

Yes No

If yes, explain

Rheumatic Fever

Yes No

Stroke

Yes No

Allergies to Drugs or Anesthetics

Yes No

If yes, list

Radiation Treatment:

Yes No

Diabetes:

Yes No

Respiratory Disease

Yes No

Epilepsy

Yes No

Headaches, Frequent or Severe

Yes No

Hepatitis, Jaundice or Liver Disease

Yes No

Cancer

Yes No

If yes, explain

Psychiatric Care

Yes No

Swollen Neck Glands

Yes No

Sinus Problems

Yes No

AIDS

Yes No

Ulcer

Yes No

Venereal Disease

Yes No

Chemical Dependency

Yes No

Pregnant

Yes No

If yes, which trimester

Other Condition

Yes No

If yes, explain

Please list any medication you are currently taking:

Name of Previous Dentist:

Do you have any specific dental concerns:

Yes No

If yes, explain

In your opinion is your Dental Health:

Poor Fair Good Excellent

Date of last Dental Cleaning:

** ALL FEES, INSURANCE CO-PAYMENTS, DEDUCTIBLES ARE DUE AT THE TIME OF SERVICE **

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 Full Name or Full Name of Responsible Party:

I have been made aware of the HIPAA/Privacy Practices (Initial):

Today's Date:

If my insurance is billed, but does not end up paying for, or covering any service, I am aware that I am the one responsible for payment of the service(s) performed at this dental office and I will be billed directly and have to pay the expected fees.

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.

Full Name

Date:

Your information will be encrypted.