Patient Information

Date*

SS/HIC/Patient ID #

Patient Name

First Name*

Last Name*

Middle Initial*

Email *

Address*

City

State

Zip

Gender*

Male

Female

Birthdate*

MM/DD/YYYY

Age*

Patient Employer/School *

Occupation*

Employer/School Address *

Employer/School Phone*

Spouse’s Name *

Insured's Birth Date*

SS#*

Spouse’s Employer*

Whom may we thank for referring you?*

Dental Insurance

Who is responsible for this account?*

Relationship to Patient*

Insurance Co.*

Group *

Is patient covered by additional insurance?*

Yes

Birthdate

Subscriber’s Name*

Subscriber’s SS#:

Relationship*

Your Insurance Co. *

Your Group # *

ASSIGNMENT AND RELEASE

Insurance Company Name*

Doctor’s Name*

I certify that I, and/or my dependent(s), have insurance coverage with the insurance company listed above, and I assign directly to the doctor named above all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature

Clear

Name (Patient, Parent, Guardian, or Representative )

Today’s Date

Patient Relationship

Phone Numbers

Phone *

Work*

Ext*

Alt. Phone*

Spouse’s Work*

Best time and place to re/Alt. you*

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

Contact Name*

Relation to Patient

Contact Number

Work Phone *

Dental History

Reason for today’s visit*

Former Dentist*

City/State *

Date of last dental visit*

Date of last dental X-rays *

Please select “Yes” or “No” to indicate if you have had any of the following:

Bad breath

Yes

Bleeding gums

Yes

Blisters on lips or mouth

Yes

Burning sensation on tongue

Yes

Chew on one side of mouth

Yes

Cigarette, pipe, or cigar smoking

Yes

Clicking or popping jaw

Yes

Dry mouth

Yes

Fingernail biting

Yes

Food collection between the teeth

Yes

Foreign objects

Yes

Grinding teeth

Yes

Gums swollen or tender

Yes

Jaw pain or tiredness

Yes

Lip or cheek biting

Yes

Loose teeth or broken fillings

Yes

Mouth breathing

Yes

Mouth pain, brushing

Yes

Orthodontic treatment

Yes

Pain around ear

Yes

Periodontal treatment

Yes

Sensitivity to cold

Yes

Sensitivity to heat

Yes

Sensitivity to sweets

Yes

Sensitivity when biting

Yes

Sores or growths in your mouth

Yes

How often do you floss?

Health History

Physician’s Name*

Date of last visit *

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.

Yes

Have you ever taken any of the group of drugs collectively referred to as “fen-phen”? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Yes

Please select “Yes” or “No” to indicate if you have had any of the following:

AIDS/HIV

Yes

Anemia

Yes

Arthritis, Rheumatism

Yes

Artificial Heart Valves

Yes

Artificial Joints

Yes

Asthma

Yes

Back Problems

Yes

Bleeding abnormally, with extractions or surgery

Yes

Blood Disease

Yes

Cancer

Yes

Chemical Dependency

Yes

Chemotherapy

Yes

Circulatory Problems

Yes

Congenital Heart Lesions

Yes

Cortisone Treatments

Yes

Cough, persistent or bloody

Yes

Diabetes

Yes

Emphysema

Yes

Do you wear contact lenses?

Yes

Epilepsy

Yes

Fainting or dizziness

Yes

Glaucoma

Yes

Headaches

Yes

Heart Murmur

Yes

Heart Problems

Yes

Hepatitis

Yes

Herpes

Yes

High Blood Pressure

Yes

Jaundice

Yes

Jaw Pain

Yes

Kidney Disease

Yes

Liver Disease

Yes

Low Blood Pressure

Yes

Mitral Valve Prolapse

Yes

Nervous Problems

Yes

Pacemaker

Yes

Psychiatric Care

Yes

Radiation Treatment

Yes

Respiratory Disease

Yes

Rheumatic Fever

Yes

Scarlet Fever

Yes

Shortness of Breath

Yes

Sinus Trouble

Yes

Skin Rash

Yes

Special Diet

Yes

Stroke

Yes

Swollen Feet or Ankles

Yes

Swollen Neck Glands

Yes

Thyroid Problems

Yes

Tonsillitis

Yes

Tuberculosis

Yes

Tumor or growth on head or neck

Yes

Ulcer

Yes

Venereal Disease

Yes

Weight Loss, unexplained

Yes

Women:

Are you pregnant?

Yes

Are you nursing?

Yes

Taking birth control pills?

Yes

Medications

List any medications you are currently taking and the correlating diagnosis:

Pharmacy Name

Telephone

Updates (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment?

Yes

For what conditions?

Are you taking any new medications?

If so, what?

Patient’s Signature

Clear

Signed On

Doctor’s Signature

Clear

Date of Signature