PATIENT INFORMATION

Date:______Home Phone#______Cell Phone#______

Patient______

Last Name First Name Middle Initial Preferred Name

Street Address______City______State______Zip______

Patient’s Social Security # ______-_____-______Birthdate___/___/___ Age____ Gender: M / F

Marital Status: __Single __Married __Widowed __Separated __Divorced

Employed by ______Occupation______

Business Address______Work Phone#______

Spouse Name______

Spouse Employed by______Spouse Work Phone#______

Who is responsible for this account?______Relationship to patient______

In case of emergency, who should be notified? ______Phone#______

Whom may we thank for referring you?______

INSURANCE INFORMATION

Name of Dental Insurance Company______Group #______

Primary Holder of Insurance______

Primary Insured’s Social Security # _____-___-_____ Primary Insured’s Birthdate ____/____/____

---PLEASE GIVE INSURANCE CARD TO OFFICE ASSISTANT TO MAKE A COPY ON YOUR FIRST VISIT

OR IF YOUR INSURANCE HAS CHANGED. THANK YOU---

Secondary Dental Insurance Company______Group #______

Name of Insured Person______

Insured’s Social Security # _____-____-_____ Insured’s Birthdate ____/____/____

MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dental care you will receive. Thank you for answering the following questions.

CIRCLE APPROPRIATE ANSWER (Leave blank if you do not understand the question)

  1. YesNoIs your general health good?
  2. YesNoHave there been a change in your health within the last year?
  3. Yes NoHave you ever been hospitalized or had a major operation?

If yes, please explain:______

  1. YesNoAre you being treated by a physician now? For what?______

Date of last Medical Exam:______Date of last Dental Appt.:______

  1. Yes NoHave you had problems with prior dental treatment?
  2. YesNoAre you in pain now?
  3. YesNoHave you ever had a serious head or neck injury?
  4. YesNoDo you use tobacco?
  5. YesNoDo you use controlled substances or recreational drugs? ______
  6. YesNoAre you taking any medications? Please list: ______

______

  1. Are you allergic to any of the following?Check all that apply

□Aspirin □Penicillin □Codeine □Acrylic □Metal □Latex □Local Anesthetics □Other______

______

  1. Women: Are you □ Pregnant/Trying to get pregnant? □Nursing □Taking oral contraceptives?

  1. Have you experienced any of the following?(Check all that apply)

□AIDS/HIV Positive

□Alzheimer’s Disease

□Anemia

□Angina (chest pain)

□Arthritis/Gout

□Artificial Heart Valve*

□Artificial Joint*

□Asthma or Hay Fever

□Blood Disease

□Blood Transfusion

□Bruise Easily

□Cancer

□Chemotherapy

□Chest Pains

□Cold Sores/FeverBlisters

□Congenital Heart Disorder

□Diabetes

□Drug Addiction

□Emphysema

□Epilepsy or Seizures

□Excessive Bleeding

□Excessive Thirst

□Fainting Spells/Dizziness

□Frequent Headaches

□Genital Herpes

□Glaucoma

□Heart Attack/Failure

□Heart Murmur*

□Heart Pace Maker*

□Heart Trouble/Disease

□Hemophilia

□Hepatitis A

□Hepatitis B or C

□Herpes

□High Blood Pressure

□Irregular Heartbeat

□Kidney Problems

□Leukemia

□Liver Disease

□Low Blood Pressure

□Lung Disease

□Mitral Valve Prolapse*

□Pain in Jaw Joints

□Parathyroid Disease

□Psychiatric Care

□Radiation Treatments

□Recent Weight Loss

□Renal Dialysis

□Rheumatic Fever*

□Rheumatism

□Scarlet Fever

□Sinus Trouble

□Spina Bifida

□Stroke

□Swelling of Limbs

□Thyroid Disease

□Tonsillitis

□Tuberculosis

□Tumors or Growths

□Ulcers

□Venereal Disease

*Condition may require medication before dental appointments

  1. Have you ever had any serious illness not listed above? □Yes□No

If Yes, please explain:______

DENTAL HISTORY

Reason for your visit ______Date of last visit______

What concerns you most about your teeth?______

YesNoAre you presently in any dental pain?______

YesNoHave you ever experienced any unfavorable reaction to dentistry?______

YesNoHave your wisdom teeth been removed?______

YesNoHave you ever lost or chipped any teeth?______

YesNoHave there been any injuries to face, mouth, or teeth?______

YesNoIs any part of your mouth sensitive to temperature? Where?______

YesNoIs any part of your mouth sensitive to pressure? Where?______

YesNoDo your gums bleed when you brush?______

YesNoDo you have any type of thumb or tongue habit?______

YesNoAre you a mouth breather?______

YesNoDo your teeth or jaws ever feel uncomfortable when you awake in the morning?______

YesNoAre you aware of your jaw clicking or popping?______

YesNoAre you aware of clenching your teeth during the day?______

YesNoHave you ever been told that you grind your teeth?______

Yes No Do you like the appearance of your smile? ______

PLEASE READ AND SIGN BELOW

  • We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly, mutual understanding between provider and patient.
  • PAYMENTS-Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the office administrator. We accept cash, checks, credit cards, or you can apply for Care Credit. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges, and any other expenses incurred in collecting your account.
  • INSURANCE – If you believe that your treatment is covered by a dental insurance policy, we will be happy to assist you in completing the necessary forms. Please understand that while this is done for your convenience, we consider each patient to be responsible for their entire balance regardless of their insurance coverage. If your insurance carrier will reimburse you directly, we ask that your account with our office be paid in full when treatment is rendered. If you request the insurance carrier to reimburse our dental office, we ask that the patient portion of the fee be paid at time of service.
  • I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
  • I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

Signature______Date___/___/___

□Adult Patient □Parent or Guardian □Spouse