WELCOME
THANK YOU FOR SELECTING OUR DENTAL HEALTHCARE TEAM. TO HELP US MEET ALL OF YOUR DENTAL
HEALTHCARE NEEDS, PLEASE FILL OUT THIS FORM.
PATIENT INFORMATION
Today’s Date: ____________
Name: ________________________________________________________________________
Soc.Sec# ________________________
Insurance ID#_____________________________
Address __________________________
City _________________ State _____ Zip ______
Male
Female
Minor
Single
Date of Birth ________________
Married
Divorced
Widowed
Separated
Employer: ___________________________ Business Address: ______________________________
PRIMARY INSURANCE
Person Responsible for Account ______________________________________________________
Relationship to Patient ________________________________
Primary Insurance _________________________
Date of birth __________
Soc. Sec. #___________________
Subscriber ID #_________________
Group #____________
Employer:______________________________
Business Address ________________________________________________________
Secondary Insurance _____________________________________________________
CONTACT INFORMATION
Home Phone: __________________ Work Phone: __________________ext.___________
Cell Phone: ___________________ E-mail Address: ______________________________
In the event of an emergency, who should we contact? ___________________________
Emergency Phone: _____________________________
HOW WERE YOU REFERRED TO OUR OFFICE?
Insurance List
Website
Advertisement
Other:________________________________________
Walk-By
Patient/Friend
If referred by a patient, please provide us with their full name
so we may include them in our gift referral program: _______________________________________________________
Please be aware that there will be a charge for all broken appointments without, at least,
24-hour notification for the General Dentist and 72-hour notification with a Specialist.
All cancellation fees must be paid prior to scheduling another appointment. The treatment that is planned for you is
specific to you. It is important for you to keep the scheduled dates and times to properly complete your treatment. A
broken appointment is a loss to three people:
1. The patient who missed the valuable time.
2. The patient who could have taken the valuable time.
3. The doctor who was fully staffed and prepared for the appointment.
Authorization and Release
I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to
me and my child during this period of such dental care to third party payors and/or other health practitioners. I authorize and request
my insurance company to pay directly to the dentist or dental groups insurance benefits otherwise payable to me. I understand that my
dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on
my behalf and my dependents. If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1.5%
on the balance then unpaid and owed will be assessed each month (if allowed by law). I realize that failure to keep this account
current may result in this office being unable to provide additional dental services. In the case of default on payment of the account, I
agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding
account balances.
X___________________________________________________Date_______________
Signature of patient or parent if minor
Financial Arrangement
Payment is required at the time of service.
For your convenience, we offer the following methods of payment. Please check the option or options you prefer.
Cash
Personal Check
Credit Card
Visa
Master Card
Discover
MEDICAL HISTORY
Name: ____________________________________________________________________________________________
Last
First
MI
Please Tell Us About Yourself
Do you have a personal physician?
Yes
No
Physician’s Name: ______________________________________Physician’s Phone: ________________________
Date of last visit: ____________________ Your current physical health is:
Good Fair Poor
Are you currently under the care of a physician?
Yes
No
Please explain: ____________________________________________________________________________________________
Do you use tobacco in any form?
Yes
No
Have you had any metal rods, pins or implants placed?
Yes
No
Do you have any artificial joints or joint replacements
Yes
No
Have you ever had any surgical procedures?
Yes
No Please list each one and year of surgery:
___________________________________________________________________________________________________________
Are you taking any medications?
Yes
No
Please provide a medication list for us to copy or list each one:
Yes No
Conditions
Yes No
Conditions
Yes No
Conditions
Abnormal Bleeding
Glaucoma
Sickle Cell Disease
Alcohol Abuse
HIV+ or AIDS
Sinus Problems
Allergies
Heart Attack
Stroke
Anemia
Heart Murmur
Thyroid Problems
Angina (chest pain)
Heart Attack
Tuberculosis
Arthritis
Hemophilia
Ulcers
Artificial Heart Valve
Hepatitis A
Asthma
Hepatitis B
Allergies
Blood Transfusion
Hepatitis C
Aspirin
Cancer
High Blood Pressure
Codeine
Chemotherapy
Kidney Problems
Dental Anesthetics
Colitis
Liver Disease
Erythromycin
Congenital Heart Defect
Low Blood Pressure
Latex
Diabetes
Mitral Valve Prolapse
Metals__________________
Difficulty Breathing
Pace Maker
Penicillin
Drug Abuse
Psychiatric Conditions
Others_________________
Emphysema
Radiation Therapy
Epilepsy
Rheumatic Fever
Females Only
Facial Surgery
Seizures
Birth control pills
Fainting Spells
Sexually Transmitted Disease
Are you Pregnant?
Fever Blisters
_______________________
# of weeks
Frequent Headaches
Shingles
Are you nursing?
Please list any other conditions you would like us to be aware of: ___________________________________________
__________________________________________________________________________________________________________
Nearest relative not living with you:
Name: ____________________________________________ Relationship: __________________________________________
Address: _______________________________________________ Telephone: _______________________________________
I understand that the information that I have given today is correct to the best of my knowledge. I also
understand that this information will be held in the strictest confidence and it is my responsibility to inform this
office of any changes in my medical status.
Patient Signature: _____________________________________________________ Date: ____________________________
DENTAL HISTORY
Date: ______________
Name: _________________________
_______________________________
Last
_____________________
First
Cell Phone Number: ________________________
MI
Email Address: ___________________________________
The primary reason for your visit today is: ____________________________________________________________
Your currently dental health is?
Good
Fair
Poor
Are you currently in pain?
Yes
No
Are your teeth sensitive to heat, cold, or anything else?
Yes
Do you require antibiotics before dental treatment?
Yes
Have you ever had gum treatment or deep cleaning?
Yes
Do you now or have you had any pain/discomfort in your jaw? (TMJ)
Are you under stress? (new job, moving, relationships)?
Yes
No
No
No
Yes
No
No
Do you snore or have sleep apnea (awaken by interruption in your breathing)?
Yes
No
Do you like your smile? Yes
No
Would you like to change your smile?
Yes
No
Are happy with the color of your teeth? Yes No
Do your gums bleed?
Yes
No
How many times do you brush per day? __________ How many times do you floss per week? ___________
Have you been informed of the value of electric toothbrush (Sonicare, etc.)?
Yes
No
Have you lost any teeth?
Yes
No
Have you ever had a serious or difficult problem with any previous dental work?
Have you ever had any unfavorable dental experiences? Yes
No
Your level of dental anxiety is: High
Medium
Low
Yes
No
When was your last dental visit? _______________ When was your last dental cleaning? _______________
Why did you leave your previous dentist? ____________________________________________________
Please circle any services below you would like our friendly staff to discuss with you during your visit:
Zoom Same Day Tooth Whitening
At Home Whitening Kits
Veneers/Lumineers
Traditional Orthodontics (Braces)
Invisalign (clear braces)
Front Teeth Bonding
Smile Makeover
Crowns or Bridges
Implants
Partials/Dentures
Nightguard
Sealants
Thank you for your time!
________________________________________
Patient Signature
_______________________________
Dentist Signature
(READ AND SIGN REVERSE SIDE)