Patient Information (CONFIDENTIAL) Date ______

SS# ______

Patient Information (CONFIDENTIAL) Date ______

Name ______Birthdate ______Home Phone ______

Address ______City ______State & Zip ______

Email ______Cell Phone ______Alternative Phone # ______

Check Appropriate Box: Female Male  Minor  Single  Married  Widowed

If Student, Name of School/College ______City ______State & Zip ______

Patient or Parent/Guardian’s Employer ______Work Phone ______

Business Address ______City ______State & Zip ______

Spouse or Parent/Guardian’s Name ______Employer ______Work Phone ______

Emergency contact Person ______Phone ______

Whom may we thank for referring you? ______

Responsible Party

Name of Person Responsible for this Account ______Relationship to Patient ______

Address ______Home Phone ______

Email ______Cell Phone ______

Driver’s License # ______Birthdate ______Bank ______

Employer ______Work Phone ______SS#/SIN ______

Is this person currently a patient in our office?  Yes  No

For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment due in Full at each appointment. Cash  Check  Visa  MasterCard Discover  I wish to discuss office’s payment policy.

Insurance Information

Name of Insured ______Relationship to Patient ______

Birthdate ______SS#/SIN ______Date Employed ______

Name of Employer ______Union or Local # ______Work Phone ______

Address of Employer ______City ______State & Zip ______

Insurance Company ______Group # ______Policy/ID # ______

Ins. Co. Address ______City ______State & Zip ______

How much is your deductible? ______How much have you used? ______Max. annual benefit ______

DO YOU HAVE ANY ADDITIONAL INSURANCE?  Yes  No IF YES, COMPLETE THE FOLLOWING:

Name of Insured ______Relationship to Patient ______

Birthdate ______SS# ______Date Employed ______

Name of Employer ______Union or Local # ______Work Phone ______

Address of Employer ______City ______State & Zip ______

Insurance Company ______Group # ______Policy/ID # ______

Ins. Co. Address ______City ______State & Zip ______

How much is your deductible? ______How much have you used? ______Max. annual benefit ______

Over Please

Patient Dental History

Name of Previous Dentist ______Phone#: ______Date of Last Exam ______Xrays taken? Yes/no

Do your gums bleed while brushing or flossing? YN

Any sensitivity to hot or cold liquids/foods? YN

Any sensitivity to sweet or sour liquids/foods? YN

Do you feel pain involving any of your teeth? YN

Have you had any head, neck or jaw injuries? YN

Do you have frequent headaches? YN

Do you clench or grind your teeth? YN

Have you ever experienced any of the following problems in your jaw?

Clicking Pain (joint, ear, side of face)

Difficulty in opening or closing Difficulty in chewing

Do you bite your lips or cheeks frequently? YN

Any difficulty extractions in thepast? YN

Any sores or lumps in or near your mouth? YN

Experienced prolonged bleeding following extractions? YN

Have you had any orthodontic treatment? YN

Do you wear dentures or partials? YN

If yes, date of placement ______

Ever received oral hygiene instructions regarding the care of your teeth and gums? YN

Do you like your smile? YN

Patient Medical History

Physician ______Office Phone ______Date of Last Exam ______

Yes No

Are you under medical treatment now...... 
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 yrs? 

If yes, please explain______

______

Are you taking any medication(s) including non- prescription medicine…………………………………...…… 

If yes, what medications are you taking? ______

______

Have you ever taken Fen-Phen/Redux? ………………
Have you ever taken Fosamax, Boniva, Actonel or any

cancer medications containing bisphosphonates? 

Have you taken Viagra, Revati, Cialis or Levitra in the last 24 hours? ……….………………..…...... ………..... 
Do you use tobacco? ……………………………...….…...… 
Do you use controlled substances? …………...……..…
Are you wearing contact lenses? …………….……....… 

10. Are you allergic to or have you had any reactions to the following:

Local Anesthetics (e.g. Novocain)………..…………...…..

Penicillin or any other Antibiotics ..……………….….….. 

Sulfa Drugs ……………………………………………………....…..

Barbiturates..…………………………………………………..….… 

Sedatives ………………………………………………….…….……. 

Iodine …………..…………………….………..……..………………... 

Aspirin………………………………………….………………………… 

Any Metals (e.g. nickel, mercury, etc.) ..…………..…….. 

Latex Rubber …………………………………….…………..……….. 

Other (please list)______

11. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 wks)?

12. Women Only:

a)Are you pregnant or think you may be pregnant?

b)Are you nursing? …………………………………….….….… 

c)Are you taking oral contraceptives? …………………. 

Check if you have or have had any of the following:

Anemia Angina Arthritis, Rheumatism AsthmaCancer Cardiac Pacemaker Chest Pains DiabetesEmphysemaEpilepsy/Convulsions Fainting Glaucoma Hay Fever/Allergies Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure High CholestrolHIV/AIDS Jaw Pain Kidney Disease Liver Disease Low Blood Pressure Mitral Valve Prolapse Radiation Treatment Recent Weight Loss/GainRespiratory Disease Rheumatic Fever Scarlet Fever Sexually Trasmitted Disease Shortness of Breath Stomach Troubles/Ulcers Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit TonsillitisTuberculosis

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group 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 series rendered on my behalf or my dependents.

______

Signature of patient (or parent/guardian if minor) Date