Welcome

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.

Patient Information

Name
Soc. Sec. #
Address

City

State
Zip
Home Phone
Cell Phone
Email
Sex
DOB
Status
Patient Employed by
Occupation
Bussiness Address
Business Phone
Business Email
Whom may we thank for referring you?
Whom may we thank for referring you?
Notify in case of emergency
Home Phone
Cell Phone
Business Phone
Email

Primary Insurance

Name
Relation to Patient
Birthdate
Soc. Sec. #
Address (if different from patient)

City

State
Zip
Home Phone
Cell Phone
Email
Person Responsible Employed by
Occupation
Bussiness Address
Business Phone
Business Email
Insurance Company
Insurance Email
Contract #
Group #
Subscriber #
Name of other dependents under this plan

Additional Insurance

Is patient covered by additional insurance?
Subscriber Name
Relation to Patient
Birthdate
Soc. Sec. #
Address (if different from patient)

City

State
Zip
Home Phone
Cell Phone
Email
Subscriber Employed by
Business Phone
Business Email
Insurance Company
Phone
Insurance Email
Contract #
Group #
Subscriber #
Name of other dependents under this plan

Dental History

What would you like us to do today?
Are you in dental discomfort today?
Former Dentist
Address
Dentist's Email
Phone
Date of last dental care
Date of last x-rays
Check yes or no if you have had problems with any of the following:
Bad breath
Bleeding gums
Food collection between teeth
Grinding or clenching teeth
Loose teeth or broken fillings
Periodontal treatment
Sensitivity to cold
Sensitivity to hot
Sensitivity to sweets
Sensitivity when biting
Sores or growths in mouth
Clicking or popping jaw
How often do you brush?
Floss?
How do you feel about the appearance of your teeth?
Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?
Other information about your dental health or previous treatment

Medical History

Physicians name
Phone
Date of last visit
Have you had any serious illnesses or operations?
If yes, describe
Are you currently under physician care?
If yes, describe
Have you ever had a blood transfusion?
If yes, give approximate dates
Have you ever taken Fen-Phen/Redux?
Women: Are you pregnant?
Nursing
Taking birth control pills?
Check yes or no whether you have had any of the follwing:
AIDS/HIV Positive
Anaphylaxis
Anemia
Arthritis, Rheumatism
Artificial heart valves
Artificial joints
Asthma
Atopic (allergy prone)
Back problems
Blood disease
Cancer
Cancer Describe
Chemotherapy
Circulatory problems
Cortisone treatments
Cough, persistent
Cough up blood
Diabetes
Epilepsy
Fainting
Food allergies
Glaucoma
Headaches
Heart murmur
Heart problems
Chemical dependency
Hemophilia/Abnormal bleeding
Herpes
Hepatitis
High blood pressure
Jaw pain
Kidney disease or malfunction
Liver disease
Material allergies (latex, wool, metal, chemicals)
Mitral valve prolapse
Nervous problems
Pacemaker/Heart surgery
Psychiatric care
Rapid weight gain or loss
Radiation treatment
Respiratory disease
Rheumatic/Scarlet fever
Shingles
Shortness of breath
Skin rash
Spina Bifida
Stroke
Surgical implant
Swelling of feet or ankles
Thyroid disease or malfunction
Tobacco habit
Tonsillitis
Tuberculosis
Ulcer/Colitis
Venereal disease
Is patient currently taking any medications? If yes, list all:
Does patient have drug allergies? If yes, list all:
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.
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I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
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