Patient Information & Medical Health History

Patient Information

Welcome to our Office! To assist us in serving you, please complete the following confidential forms. The information provided is important to your dental health.

Patients Name

Preferred Name

Birth Date

Home Phone

Work Phone

If minor, parents' names

Address

City

State

Zip

Employer

Occupation

Spouse's Name

Spouse's Employer

Whom may we thank for referring you to our office?

Billing, Credit & Insurance Information

Dental Insurance Company

Social Security Number

ID Number

Group Number

Covered by Spouse's Insurance

Yes No

Spouse's Dental Insurance Company

Social Security Number

ID Number

Group Number

Birth Date

Medical Health History

Are you allergic to, or have you reacted adversely to any of the following?

Latex materials

Penicillin or other antibiotics

Local anesthetics (Novocain)

Codeine or other narcotics

Sulfa drugs

Barbiturates, sedatives or sleeping pills

Aspirin

Other:

Are you taking any of the following?

Aspirin

Anticoagulants (blood thinners)

Antibiotics or sulfa drugs

High blood pressure medicine

Antidepressants or tranquilizers

Insulin, Orinase, or other diabetic drugs

Nitroglycerin

Cortisone or other steroids

Osteoporosis (Bone Density medicine)

Other:

Women:

Pregnant

Taking hormones or oral contraceptives

Expected Delivery Date

Do you smoke or use chewing tabacco?

Yes No

Name of your physician

Do you have any disease, condition or problem not listed above?

Dental History

Reason for today's visit:

Date of last dental care:

Date of last X-Rays:

Former dentist

Address

How often do you floss?

How often do you brush?

Authorization and Release

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my dentist of any changes to my health.

I certify that I, and/or my dependent(s) have insurance converge with:

This consent will end when the treatment plan is completed or three years from the date signed below.

Signature of patient (or parent)

Date

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

Your information will be encrypted.