Patient Information and Medical/Dental History Form

Please take a moment to enter your information to help us ensure the quality of your care is excellent.
Your medical and dental history will allow us to serve you more effectively and in a way that watches out for your overall health and well-being. All information is strictly confidential.

Title:

Name:

Birth date:

Address:

Apartment Number:

Postal Code:

Home Phone:

Mobile Phone:

Work Phone:

May we contact you at work:

Yes No

Email Address:

Do you prefer appointment confirmations by phone or by email?

In case of emergency, whom should we contact?

Name:

Relationship:

Phone Number:

Name of Family Doctor:

Phone:

Whom may we thank for referring you to our practice?

Do you have dental insurance?

Yes No

If yes, name of insurance provider:

Certificate Number:

Policy Number:

Who is the primary holder of this insurance?

Primary Insurance Holder's Date of Birth

Employer:

Has there been any change in your general health in the past 5 years?

Yes No

If yes, please explain:

When was your last medical checkup?

Please list all of your medications and dosages below. (Prescription, Non-prescription or Herbal supplements)

Do you have any allergies?

Yes No

If yes, please list:

Have you ever had a peculiar or adverse reaction to any medications or injections:

Yes No

If yes, please explain:

Are there any medical conditions that run in your family? If yes, please list below:

Are you pregnant?

If yes, how many weeks?

Have you had any illnesses/surgeries/operations not listed above? If yes, please list below:

What is the reason for your dental visit today?

When was your last dental appointment?

What was done in that appointment?

When were dental x-rays last taken?

Have you ever had complications following dental treatment?

Have you ever had orthodontic treatment (braces or Invisalign)?

Yes No

How often do you brush your teeth?

How often do you floss your teeth?

Do your gums bleed when you brush or floss?

Yes No

Are any of your teeth sensitive to hot or cold temperatures?

Yes No

Are any of your teeth currently causing you pain?

Yes No

Are any of your teeth loose?

Yes No

Do you think you grind or clench your teeth, either during the day or when sleeping?

Yes No

Do you have any dental implants, or full or partial dentures?

Yes No

If you could change anything about your mouth, teeth or smile, what would it be?

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.

I HEREBY CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT PROVIDING INCORRECT OR INACCURATE INFORMATION HAS THE POTENTIAL OF BEING HAZARDOUS TO MY HEALTH.

Name/Signature:

Date:

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY OUTSTANDING BALANCE FOR SERVICES PROVIDED THAT ARE NOT FULLY COVERED BY MY INSURANCE. I CONSENT AND AGREE TO BE FINANCIALLY RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED ON MY BEHALF OR ON BEHALF OF MY DEPENDENTS) IF ANY. I AGREE THAT DR. SHIEWITZ OR HER STAFF CAN COLLECT, USE AND DISCLOSE MY PERSONAL INFORMATION TO DELIVER SAFE AND EFFICIENT ORAL CARE, AND FOR COLLECTION PURPOSES.

Name/Signature:

Date:

Your information will be encrypted.