New Patient Form

Patient Information

Date

SS/HIC/Patient ID #

E-mail

Last Name

First Name

Middle Initial

Address

City

State

Zip

Sex

Male Female

Age

Birth Date

Marital Status

Married Widowed Single Minor Separated Divorced Partnered

# of Years Partnered

Patient Employer/School

Occupation

Employer/School Address

Employer/School Phone

Spouse's Name

Birth Date

SS#

Spouse's Employer

Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account?

Relationship to patient

Insurance Company

Group #

Is patient by additional insurance?

Yes No

Subscriber's Name

Birth Date

SS#

Relationship to Patient

Insurance Company

Group #

Assignment and Release

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

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 changes 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

Home

Work

Ext.

Alt. Phone

Spouse's Work

Best Time and Place to reach you

In Case of Emergency, Contact

(Specify someone that does not live in your household)

Name

Relationship

Phone

Alt. Phone

Dental History

Reason for Today's Visit

Former Dentist

City

State

Date of Last Dental Visit

Date of Last Dental X-rays

Please Mark "Yes" or "No" to Indicate if you have had any of the Following:

Bad Breath

Yes No

Bleeding Gums

Yes No

Blisters on Lips of 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 of popping jaw

Yes No

Dry Mouth

Yes No

Fingernail Biting

Yes No

Food collecting 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 used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.

Yes No

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).

Yes No

Please Mark "Yes" or "No" to indicate if you have had any of the following:

AIDS/HIV

Yes No

Anemia

Yes No

Arthtitis, Rheumatism

Yes No

Artificial Heart Valves

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Back Problems

Yes No

Bleeding abnormally, with extractions or 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

Do you wear contact lenses?

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

Hepatitis Type

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 or 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

Women:

Are you Pregnant?

Yes No

Due Date

Are you Nursing?

Yes No

Taking birth control pills?

Yes No

Medications

Medication and dosage

Pharmacy Information

Pharmacy Name

Phone

Allergies

Do you have any Allergies?

Aspirin

Barbiturates (Sleeping Pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicilin

Sulfa

Other

Other Explanation

Updates (To be filled out within the office at a future appointment.)

Update #1

Has there been any change in your health since your last dental appointment?

Yes No

For what conditions?

Are you taking any new medications? If so, what?

Patient's Signature

Date

Doctor's Signature

Date

Update #2

Has there been any change in your health since your last dental appointment?

Yes No

For what conditions?

Are you taking any new medications? If so, what?

Patient's Signature

Date

Doctor's Signature

Date

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