WELCOME We are pleased to welcome you to our practice. Please take a few min utes to fill out this form as completely as you can. If you have questions, we'll be glad to help you. We lo ok forward to working with you in maintaining your dental health. Patient Information Name______ __ Last Name First Name Mlodl<> Initial Address ________________________________________________________________ HomePhone __________________ City ___________________________________________ State ______ Zip _______ Email _______________________ Sex 0 M 0 F Age _______ Birthdate ____________ o Single 0 Married 0 Widowed 0 Separated 0 Divorced Patient Employed by __________________________________________ Occupation _____________________________ Business Address __________________________________________ Business Phone _________________________ Whom may we thank for referring you? ___________________________________________________________________ ________________________ Home Phone ________________ Work Phone ______________ Cell Phone ___________________-'-_______________ Business Email ___________________________________ Primary Insurance Person Responsible for Account Last Name First Name Middle Initiat Relation to Patient ______________________________ Birthdate _________________ Soc. Sec. # ___________ _ Address (if different from patient) _____________ --:-__________________________ Home Phone _____________________ City ____________________________________________________________________ State ___ Zip ________ Cell Phone __________________________--'-_____________________ Email _______________________________ _ Person Responsible Employed by _____________---=-__________________ Occupation _____________________________ Business Address ____________________________________________ Business Phone ___________ ____________. Business Email ________________________________________________________________________________ Insurance Company __________________________________________ Phone _____________________________ _ Contract # _______________________________________ Group 11 _______________ Subscriber's II __________ _ Name(s) of other dependents under this plan __________________________________________________________________ Additional Insurance Is patient covered by additional insurance? 0 Yes 0 No Subscriber's Name _________________________________ Relation to Patient __________________ Birthdate ___ _ Address (if different from patient) ____________________________________________ Soc . Sec. #__________________ City __________________________________________ State _____ Zip _____ Home Phone _________________ Cell Phone _________________________________________________ Business Phone ______________________ Subscriber Employed by __________________________________________ Business Email ______________________ Insurance Company ____________________________ Phone _________________ Insurance Email _______________ Contract # ___________________________________ Group 11 _______________ Subscriber's /I __________________ _ Name(s) of other dependents under this plan __________________________________________________________ Please complete both sides.
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WELCOME We are pleased to welcome you 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 you in maintaining your dental health.
Patient Information Name______~~----------------~~----------------~~~~ Soc.Sec. #----------------------------__
Date of last dental care _________________ Date of last X-rays _ _____ ________ ____
Check Y for yes or N for no if you have or have not had the following :
o Y ON Bad breath 0 y O , Food collection between teeth O Y D t\ PeJiodontal treatment D Y 0 1 Sensitivity to sweets
o y 0 Bleeding gums 0 Y O N Grinding or clenching tceth D Y D Sensitivity to cold O YO N Sensiti vity when biting
o Y O N Clicking or popping Jaw 0 Y ':J N Loose teeth or broken fillings D Y O N Sensitivity to hot O YO N Sores or growths in mouth
How often do you brush? _________________--'-_____ How often do you floss? _ _ _________
How do you feel about the appearance of your teeth? ________--_____________________ _
Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? 0 Y :::J
Medical History Physician's name _______________ Address________________ Pllone ______ _
Physician's Email .. _______________________ Date of last visit _____________ _ _
Have you had any serious illnesses or operations? D Y D N If yes. describe _______ _ _____ _________
Are you currently under physician care? D y O N If yes, describe _ __________________________
Have you ever had a blood transfusion? D y D N If yes, give approximate dates _____________________
Have you ever taken Fen-Phen/Redux? D y D N
Women: Are you pregnant? D y D N Nursing? D y D N Taking birth control pills? D y D N
Check Y for yes or N for no if you have or have not had any of the following:
O Y[J N AlDS/HfV Positive O Y '"""] "J" Cough. persistent O y O Jaw pain O YO N Shingles
O YO 'i Anaphyla,\is O y O Cough up blood O y O " Kidney disease or malfunction O y DN Shot"tness of breath
OY O N Anem.ia O YO Diabetes O YO 1 Liver di sease O YO N Skin rash
O YO "! Arthritis. Rheumatism 0 y O . 1 Epilepsy O y O N Spina Bifida O YO N 'v1aterial allergies O Y O N Artificial heart valves e y O Fni,nting O y O N Stroke1
(latex. wool. mewl, chemicals) O YO nificial joints O YC "J Food allergic:; O YO N Surgical implant O y O Mitral valve prolapse O YO N Asthma O YO N Glaucoma O YO , Swelling of feet or
1O y O Nervoili problemsO Y O N Atopic (allergy prone) 0 YO N Headaches ankles
O Y O N PacemakerfHeart surgery O y O N Back problems O YO N Heart murmur D YO N Thyroid disease or O Ve N Psychiatric care
O Y O ~ Blood disease O YD N Heart problems malfunction D YC N Rapid .",.eight gain or loss D YO N Cancer Describe O YD N Tobacco habit
O YO N Chemical dependency D YO N Hemophilia! Abnormal bleeding 0 y e N Radiation treatment O y D N Tonsillitis
O Y O N Chemotherapy O YD Herpes O YO N Respiratory disease D YO N Tuberculosis
O Y O N Circulatory problems D YD N Hepatitis O YD i'-: Rheumatic fever D YD N Ulcer/Colitis
O YO N Cor1isone treatments O YO "i High blood pressure O Y O N Scarlet fever O YO N Venereal disease
List medications you are currently taking, If any: List drug allergies, If any:
Authorization I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.
I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Signature_____________ __________ _________ ___ Date _ _ ________
Payment is due in full al ti me of treatment unless prior arrangements have been approved.
