Patient Information
NAME:
LAST NAME
FIRST NAME
MIDDLE INITIAL
PREFERRED NAME
ADDRESS:
STREET
APT NUMBER
CITY
STATE
ZIP
Employer
Birth Date
Driver License
STATUS
Height
Weight
GENDER
PHONE:
Home
Social Security Number
Work
Cell
Email
EMERGENCY CONTACT:
Name
Phone
How did you hear about us?
Referred By
Other
Insurance
1 - Primary Dental Carrier
1 - Insurance Co Name:
1 - Insurance Phone Number
1 - Insuredís Name:
1 - Birth Date:
1 - ID Number:
1 - Insuredís Employer:
1 - Group Number:
1 - Relationship to Patient:
2 - Secondary Dental Carrier:
2 - Insurance Co Name:
2 - Insurance Phone Number
2 - Insuredís Name:
2 - Birth Date:
2 - ID Number:
2 - Insuredís Employer:
2 - Group Number:
2 - Relationship to Patient:
If Patient Is Under 18 Years Of Age
Responsible Party Address
Responsible Party - Group Number:
Responsible Party - Relation to Patient
Responsible Party - STREET
Responsible Party - CITY
Responsible Party - STATE
Responsible Party - ZIP
The information on this page is correct to the best of my knowledge
PATIENT OR PARENT/GUARDIAN SIGNATURE
Other Information
Physicianís Name
Physicianís Phone
Have you had a serious illness or operation?
If yes, please describe
Are you currently under physician care?
If yes, please describe
Medical History and Information:
Please check those conditions that have ever applied to you
Conditions
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Arthritis
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer
Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Facial Surgery
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
HIV+ Aids
Heart Attack
Joint Replacement
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Psychiatric Problems
Radiation Therapy
Rheumatic Fever
Seizures
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Allergies
Aspirin
Codeine
Erythromycin
Latex
Metals
Penicillin
Other Allergies
Do you Smoke or use Tobacco?
Women Only
Are you taking Birth Control Pills?
Are you pregnant?
Are you nursing?
Please list any medications you are currently taking
Have you EVER taken any bisphosphonates? (e.g. Fosomax, Actonel)
Treatment Authorization
By submitting this form I agree that the information on this page is correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.
PLEASE CHECK A SOURCE IN WHICH YOU WOULD LIKE TO RECEIVE APPOINTMENT REMINDERS
Email
Text Message
Both Email and Text Message
Email Address
Cell Phone