Confidential Patient Information Adult - 18 and up
Today’s date:______
Patient Name: ______Birth Date:______
Last First MI Nickname
Address______
Street City State Zip
[ ] Male [ ] Female [ ] Married [ ] Single [ ] Divorced [ ] Widowed
Driver’s License #:______Employer:______
√ Best Contact: Home ( ) ______Cell ( ) ______
Work ( ) ______E-Mail ______
May Dr Danner and his dental team contact you, and all other responsible parties on your account, on your cell phone or mobile devices concerning any and all aspects of your account? YES NO
Insurance Information
Primary Insurance Co: ______Policy #______
Group Plan:______Group Plan # ______
Insured Person’s Name:______Birth Date:______SSN______Employer:______Relationship to Patient:______
Secondary Insurance: Yes No If yes, give insurance card at check in.
Responsible Party
Name:______Relationship:______
Address:______City:______State:______Zip:______
Phone: (Home)______(Work)______(Cell)______
Referral Information
Whom may we thank for referring you to our dental practice?
□ Friend/ Family/Colleague □ Know Dr. Danner □ Know Team Member ______
Their name______□ Search Engine (Yahoo, Yelp, Google) □ Insurance Provider
□ Social Media ( Facebook/Twitter/ Instagram) □ Website □ Other ______
Dental Information
What prompted you to seek dental care at this time?______
How long since your last thorough dental examination?______leaned?______X-Rays?______
Has the fear of discomfort or a past experience kept you from regular dental visits?______
Explain:______
How often do you brush your teeth?______Floss your teeth?______
Are you troubled with bad breath?______Do your gums bleed easily, feel tender or irritated?______
Are your teeth sensitive to hot, cold or sweets?______Do you frequently snack between meals on sweets, starches or gum?______
Is there anything about your smile that you do not like?______What would you change about your teeth or smile?______
Do you have frequent headaches?______Is your bite comfortable when biting or chewing food?______
Do you have clicking or popping noises when opening your mouth?______
Are you aware of grinding or clenching your teeth?______At night?______
Name of previous dentist?______Phone:______
May we request your previous dental records to facilitate proper treatment in our office?______
To the best of my knowledge, all of the preceding information is correct. If at any time any of the above information changes, I will notify the doctor or his team. I understand that I am responsible for payment when services are rendered unless other arrangements have been made. If insured, I authorize my group insurance benefits be payable to Dr. Russell Danner, DDS.
Patient or Guardian Signature:______Date:______