Kindly fill out the form below so we can serve you better. Thank you
First Name*
Last Name*
Social Security Number*
Phone Number*
Email Address*
Unit No., Building Name, Street*
City*
State*
Zip Code*
Birthdate*
Marital Status* SingleMarriedDivorcedSeparated
Gender* MaleFemale
Driver's License No. & State*
Primary Insurance Company*
Group*
Subscriber*
Secondary Insurance Company
Group
Subscriber
Same as Patient Information
Responsible Party's Name*
Home Phone*
Relationship To Patient*
Employer*
Occupation*
Work Phone*
Spouse's Name
Social Security Number
Home Phone
Unit No., Building Name, Street
City
State
Birthdate
Marital Status
Relationship To Patient
Driver's License No. & State
Employer
Occupation
Work Phone
Who Selected This Office?* SelfSpouseParentEmployer
Where did you find the Phone Number to this Office?* Referred by a friendYellow PagesRelativeInsurance PlanWelcome WagonTV/Radio AdNewspaper AdDirect MailingSign by BuildingOther
Other (Please specify)
If you were referred, whom may we thank for referring you?*
I will answer all health questions to the best of my knowledge*
After an explanation by the doctor, I hereby authorize the performance of dental services upon the above-named patients and whatever procedures that the judgment of the doctor may decide in order to carry out these procedures. I also authorize and request the administration of any anesthetics and x-rays as may be deemed necessary and advisable by the doctor*
Consenting Person's Relation to the Patient?*
This office depends upon reimbursement from the patient for the costs incurred in their case. The financial responsibility of each patient must be determined before treatment. As a condition of treatment by this office, I understand financial arrangements must be made in advance. All emergency dental services, or any dental service performed without prior financial arrangements, must be paid for at the time the services are performed. I understand that dental services furnished to me are charged directly to me and that I am personally responsible for payment. If I carry insurance, I understand that this office will help prepare my insurance forms to assist in making collections from insurance companies and will credit such collections to my account. However, this dental office cannot render services on the assumption that charges will be paid by an insurance company
Assignment of Insurance: I hereby authorize releases of any information needed and also authorize my insurance company to pay directly to this Office benefits accruing to me under my policy. I understand that the fee estimate listed for this dental care can only be extended for a period of 90 days from the date of the patient’s examination. I also understand that in order to collect my debt, my credit history may be checked through the use of my Social Security Number or any other information I have given you. I agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred including reasonable attorney’s fees. I grant my permission to you, or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions and agree to their content
I agree to the terms and conditions.*
Why have you come in to see us today? (e.g.: pain, checkup, etc.)*
Previous Dentist*
Reasons for changing dentists*
What problems have you had with past dental treatment?*
Are you nervous about seeing a dentist?* YesNo
If yes, please tell us why.
How often do you brush?*
Do You Floss?* YesNo
How often?
I clench or grind my teeth during the day or while sleeping. YesNo
My gums feel tender or swollen YesNo
My gums bleed while brushing or flossing. YesNo
I have problem eating. YesNo
I like my smile. YesNo
I have had orthodontics.YesNo
I prefer tooth-colored fillings.YesNo
I have had a facial or jaw injury.YesNo
I avoid brushing part of my mouth due to pain.YesNo
I want my teeth straigh.YesNo
I want my teeth whiter.YesNo
What are your dental priorities? (e.g.: apprentice, dental health, financial considerations, etc.)*
I consider my health to be (please check one)* ExcelentGoodFairPoor
Heart Disease YesNo
Heart Murmur/Mitral Valve ProlapseYesNo
Stroke YesNo
Congenital Heart Lesions YesNo
Rheumatic Fever YesNo
Abnormal Blood Pressure YesNo
AnemiaYesNo
Prolonged Bleeding Disorder YesNo
Tuberculosis or Lung Disease YesNo
Asthma YesNo
Hay Fever YesNo
Sinus Trouble YesNo
Epilepsy/Seizures YesNo
Ulcers YesNo
Implants/Artificial Joints YesNo
I smoke or use tobacco. YesNo
If Yes, Please checkHipKneeOther
If yes, how much per day?
How many years?
I have consumed alcohol within the last 24 hours YesNo
I usually take an antibiotic prior to dental treatment. YesNo
Have you ever taken Fen-Phen or Redux? YesNo
I have had major surgery. YesNo
If Yes, Year?
Type of Operation
Liver Disease YesNo
Jaundice YesNo
Hepatitis YesNo
Diabetes YesNo
Hepatitis Type
Excessive Urination and/or Thirst YesNo
Infectious Mononucleosis (Mono) YesNo
Herpes YesNo
Arthritis YesNo
Sexually Transmitted/Venereal Disease YesNo
Kidney Disease YesNo
Tumor or Malignancy YesNo
Cancer/Chemotherapy YesNo
Radiation Treatment YesNo
History of Drug Treatment YesNo
Aids YesNo
Immune Suppressed Disorder YesNo
Hearing Loss YesNo
Fainting Spells YesNo
Glaucoma YesNo
History of Emotional or Nervous Disorders YesNo
Are you taking birth control medication? YesNo
Are you or could you be pregnant or nursing? YesNo
Do you have any other medical problem or medical history NOT listed on this form? YesNo
If Yes, Please specify
Aspirin YesNo
Ibuprofen YesNo
Sulfa Drugs/Sulfites/Sulfides YesNo
Penicillin YesNo
Codein YesNo
Latex, Metals, Plastics YesNo
Local Anesthetics (Novocaine) YesNo
Other Medications? YesNo
Which ones?
Medicine*
Condition*
Physician's Name*
Phone*
Address*
Fax*
Name*
Relationship*
Doctor's Signature
Date
Patient's Signature
