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Patient Information

Date:
SS/HIC/Patient ID#(collect at office):
Patient Name*:
Address:
City:
State: Zip:
E-mail*:
Sex: MF
Age:
Birthdate
MarriedWidowedSingleMinorSeparatedDivorcedPartnered
How many years partnered: years 		Occupation:
Patient Employer/School:
Employer/School Address:

Spouse's Name:
Birthdate:
SS# (collect at office):
Spouse's Employer:
Whom may we tank for referring you?

Dental Insurance

Subscriber's Name:
Relationship to Patient:
Birthdate: SS#(collect at office):
Insurance Co.:
Group #: Phone: 		Is patient covered by secondary insurance? YesNo
Subscriber's Name:
Relationship to Patient:
Birthdate:
SS#(collect at office):
Insurance Co.:
Group #:
Phone:

Phone Numbers

Home*: Work: Ext. Alt.:
Spouse's Work: Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
Name: Relationship: Home: Work: Ext. Alt. Phone:

Dental History

Reason for today's visit:

Former Dentist:
City/State:
Date of last dental visit:
Date of last dental X-rays:
How often do you floss?
How often do you brush?
Do you wear contact lenses? YesNo 		Please check "yes" or "no" to indicate if you have had any of the following:

Bad Breath:
YesNo
Bleeding gums:
YesNo
Blisters on lips or mouth:
YesNo
Burning sensation on tongue:
YesNo
Chew on one side of mouth:
YesNo
Cigarette, pipe, or cigar smoking:
YesNo
Clicking or popping jaw:
YesNo
Dry mouth:
YesNo
Fingernail biting:
YesNo
Food collection between the teeth:
YesNo
Foreign objects in mouth:
YesNo
Grinding teeth:
YesNo
Gums swollen or tender:
YesNo
Jaw pain or tiredness:
YesNo
Lip or cheek biting:
YesNo
Loose teeth or broken fillings:
YesNo
Mouth breathing:
YesNo
Mouth pain:
YesNo
Orthodontic treatment:
YesNo
Pain around ear:
YesNo
Periodontal treatment:
YesNo
Sensitivity to cold:
YesNo
Sensitivity to heat:
YesNo
Sensitivity to sweets:
YesNo
Sensitivity when biting:
YesNo
Sores or growths in mouth
YesNo

Medical History

Physician's Name: Date of last visit: Phone: Pharmacy: Phone:
Please check "yes" or "no" to indicate if you have had any of the following:

AIDS:
YesNo
Anemia:
YesNo
Arthritis, Rheumatism:
YesNo
Asthma:
YesNo
Back Problems:
YesNo
Cancer:
YesNo
Chemical Dependency:
YesNo
Chemotherapy:
YesNo
Circulatory Problems:
YesNo
Cortisone Treatments:
YesNo
Cough, persistent or bloody:
YesNo
Diabetes:
YesNo
Emphysema:
YesNo
Epilepsy:
YesNo
Fainting or dizziness:
YesNo
Glaucoma:
YesNo
Headaches:
YesNo
Heart Problems:
YesNo
Hepatitis:
YesNo
Hepatitis Type:
Herpes:
YesNo
Have you ever had any complications following dental treatment?
YesNo
If yes, please describe below:
Have you ever been hospitalized or do you have any other health concerns?
YesNo
If yes, please describe below:
Women: Are you pregnant?
YesNo
Due Date
Are you nursing?
YesNo
Taking birth control pills?
YesNo
High Blood Pressure
YesNo
HIV Positive
YesNo
Jaundice
YesNo
Jaw Pain
YesNo
Kidney Disease
YesNo
Liver Disease
YesNo
Low Blood Pressure
YesNo
Nervous Problems
YesNo
Psychiatric Care
YesNo
Radiation Treatment
YesNo
Respiratory Disease
YesNo
Scarlet Fever
YesNo
Shortness of Breath
YesNo
Sinus Trouble
YesNo
Skin Rash
YesNo
Special Diet/Weight Loss
YesNo
Stroke
YesNo
Swollen Feet or Ankles
YesNo
Swollen Neck Glands
YesNo
Thyroid Problems
YesNo
Have you ever taken any of these medications?
Blood Thinners
YesNo
  Coumadin
YesNo
  Warfarin
YesNo
Diet Medications
YesNo
  Dexfenfluramine
YesNo
  Fen-phen
YesNo
  Pondimin
YesNo
  Redux
YesNo
Levoxyl
YesNo
Synthroid
YesNo
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.
YesNo
Tonsillitis
YesNo
Tuberculosis
YesNo
Ulcer
YesNo
Venereal Disease
YesNo
Have you ever had or been diagnosed with:
Artificial Heart Valve:
YesNo
Artificial Joints, Screws, Pins, etc.:
YesNo
Bleeding abnormally, with extractions or surgery
YesNo
Blood Disease
YesNo
Congenital Heart Lesions
YesNo
Heart Murmur
YesNo
Hernia Repair
YesNo
Mitral Valve Prolapse
YesNo
Pacemaker
YesNo
Rheumatic Fever
YesNo
Are you allergic to:
Aspirin
YesNo
Barbiturates
YesNo
Codeine
YesNo
Ibuprofen
YesNo
Local Anesthesia
YesNo
Metals (i.e. gold)
YesNo
Penicillin
YesNo
Other

Please PRINT all medications now taking:

Signatures

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

Insurance Assignment: I certify that I, and/or my dependent(s), have insurance with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. In 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 doctor 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 service. This consent will end when my current treatment plan is completed or one year from the date signed below.

Authorization to Release Protected Health Information: In understand that there may be a need to consult with other health care providers. I voluntarily authorize Dr. to use and/or disclose my Protected Health Information (PHI) related to . The information will be used and/or disclosed for the purpose of . I authorize Dr. to receive and use the information.

This authorization will end when my current treatment plan is completed or one year from the date signed below. I understand that once the information is released it may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. I understand that I may revoke this authorization at any time by notifying, in writing, the above-named doctor disclosing the PHI. However, if I do revoke this authorization, it will not have any effect on any actions taken by the above-name doctor disclosing the PHI prior to their receipt of the revocation. I understand that my treatment cannot be conditioned on whether I sign this authorization. I understand I may refuse to sign this authorization.

Please print name of Patient, Parent, Guardian or Personal Representative:

Relationship to Patient:

Date:

Signature:
Use finger on smart device or mouse to sign this form before clicking submit

We are pleased to welcome you and/or your child to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we’ll be glad to help you. We look forward to working with your in maintaining your dental health.

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