New Patient Information

Order Number

First Name *

Last Name *

Middle Initial

Email *

Address *

City *

State *

ZIP *

Cell Phone

Home Phone

Social Security Number *

Current Dentist

Employer

Occupation

Business Address

Business Phone

Date of Birth *

Sex *

Marital Status *

Emergency Contact *

Emergency Contact Home Phone *

Emergency Contact Work Phone

Preferred Dentist

Person responsible for account *

Whom may thank for referring you?

If patient is a minor / other parent information

Name

Relation to Patient

Date of Birth

Social Security Number

Address

Phone

Business Address

Business Phone

Primary Dental Insurance

There is a refile charge for incorrect insurance information

Insured's Name

Phone Number

Address (if different from patient)

City

State

ZIP

Relation to Patient

Insured's Date of Birth

Social Security Number

Insured Employed By

Business Phone

Employer Address

Acknowledgement of Privacy Practices

Patient Name *

Date of Birth *

Medical Information and / or test results can be given to: *

Leave message on answering machine / voicemail *

Cell Phone

Home Phone

Work Phone

Patient Information

How can we help you with your dental needs?

Do you now or have you ever experienced pain or discomfort in your jaw joint? *

On a scale of 1-10 (10 being highest), what priority do you give your teeth? *

Do you usually breathe through your mouth while you're awake? *

Do you usually breathe through your mouth while asleep? *

Have you ever experienced an adverse reaction during a medical or dental procedure? *

Date of last dental care *

Other information about your dental health or previous treatment

Medical History

Physician's Name

Physician's Phone Number

Date of last visit to physician

Have you had any serious illnesses (hospitalizations or surgeries? *

Have you ever had a blood transfusion? *

Women: Are you pregnant?

List medications you are taking, if any

List drug allergies, if any

Please check all that you have had:

AIDS/HIV Positive Anaphylaxis Anemia Arthritis, Rheumatism Artificial heart valves Artificial joints Asthma Atopic (allergy prone) Back problems Blood disease Cancer Chemical dependency Chemotherapy Circulatory problems Cortisone treatments Cough, persistent Cough up blood Diabetes Epilepsy Fainting Food allergies Glaucoma Headaches Heart murmur Heart problems Hemophilia / Abnormal bldding Herpes Hepatitis High blood pressure 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 Sinus problems Skin rash Spina Bifida Stroke Surgical implant Swelling of feet or ankles Thyroid disease or malfunction Tobacco habit Tonsillitis Tuberculosis Ulcer / Colitis Venereal disease

Authorization

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 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.

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.

Authorization Checkbox

I Agree With the Above Statements

Electronic Signature

Please type your full name to sign this form *

If patient is a minor / other parent information

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