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appointment ask forms

New Patient Information Form

Print the Patient Forms      

We are pleased you have selected us to provide dental for you and your family.

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Whom may we thank for referring you to our office?

Patient Information

Name  Last Name             First Name             Initial           Soc. Sec. # 

Address  Street                                City                  State                         Zip
Home Phone        Cell Phone
Email     

Sex:  

Male 

Female 

Birthdate 

Marital status:  

Single 

Married 

Widowed 

Separated 
Divorced 

Patient Employed by      Occupation 
Business Address      Business Phone 
Business Email     
Whom may we thank for referring you?     
Notify in case of emergency      Home Phone 
Cell Phone      Business Phone 
Email 

Primary Insurance

Person Responsible for Account  Last Name             First Name             Initial           Relation to Patient 
Birthdate      Soc. Sec. # 
Address (if different from patient) Street                                City                  State                         Zip
Home Phone  Cell Phone 
Email 
Person Responsible Employed by  Occupation 
Business Address  Business Phone 
Business Email     
Insurance Company  Phone  Insurance Email 
    
Contract #        Group #  Subscriber # 
Name of other dependents under this plan      

Additional Insurance

Is patient covered by additional insurance? 

Yes

No

Subscriber Name        Relation to Patient 
Birthdate      Soc. Sec. # 
Address (if different from patient)    Street                                City                  State                         Zip
Home Phone      Cell Phone 
Email 
Subscriber Employed by     Business Phone 
Business Email     
Insurance Company      Phone 
Insurance Email     
Contract #        Group #  Subscriber # 
Name of other dependents under this plan      

Dental History

What would you like us to do today?    
Are you in dental discomfort today?    
Former Dentist     Address 
Dentist's Email     Phone 
Date of last dental care     Date of last x-rays 
Check "Yes" or "No" if you have had problems with any of the following:

Bad breath:
Yes    

No

Bleeding gums:
Yes    

No

Clicking or popping jaw:
Yes    

No

Food collection between teeth:
Yes    

No

Grinding or clenching teeth:
Yes    

No

Loose teeth or broken fillings:
Yes    

No

Periodontal treatment:
Yes    

No

Sensitivity to cold:
Yes    

No

Sensitivity to hot:
Yes    

No

Sensitivity to sweets:
Yes    

No

Sensitivity when biting:
Yes    

No

Sores or growths in mouth:
Yes    

No


Medical History

Physician's name 
Phone      Date of last visit 

Have you had any serious illnesses or operations?
Yes    

No

If yes, describe
   

Are you currently under physician care?
Yes

No

If yes, describe
   

Have you ever had a blood transfusion?
Yes    

No

If yes, give approximate dates
   

Have you ever taken Fen-Phen/Redux? 

Yes    

No

Are you pregnant?
Yes    

No

Nursing?
Yes    

No

Taking birth control pills?
Yes    

No

Check "Yes" or "No" if you have had problems with any of the following:

AIDS/HIV Positive:
Yes    

No

Anaphylaxis:
Yes    

No

Anemia:
Yes    

No

Arthritis, Rheumatism:
Yes    

No

Artificial heart valves:
Yes    

No

Artificial joints:
Yes    

No

Asthma:
Yes    

No

Atopic (allergy prone):
Yes    

No

Back problems:
Yes    

No

Blood disease:
Yes    

No

Cancer:
Yes    

No

Chemical dependency:
Yes    

No

Chemotherapy:
Yes    

No

Circulatory problems:
Yes    

No

Cortisone treatments:
Yes    

No

Cough, persistent:
Yes    

No

Cough up blood:
Yes    

No

Diabetes:
Yes    

No

Epilepsy:
Yes    

No

Fainting:
Yes    

No

Food allergies:
Yes    

No

Glaucoma:
Yes    

No

Headaches:
Yes    

No

Heart murmur:
Yes    

No

Heart problems:
Yes    

No

Hemophilia/Abnormal bleeding:
Yes    

No

Herpes:
Yes    

No

Hepatitis:
Yes    

No

High blood pressure:
Yes    

No

Jaw pain:
Yes    

No

Kidney disease or malfunction:
Yes    

No

Liver disease:
Yes    

No

Material allergies
(latex, wool, metal, chemicals):
Yes    

No

Mitral valve prolapse:
Yes    

No

Nervous problems:
Yes    

No

Pacemaker/Heart surgery:
Yes    

No

Psychiatric care:
Yes    

No

Rapid weight gain or loss:
Yes    

No

Radiation treatment:
Yes    

No

Respiratory disease:
Yes    

No

Rheumatic/Scarlet fever:
Yes    

No

Shingles:
Yes    

No

Shortness of breath:
Yes    

No

Skin rash:
Yes    

No

Spina Bifida:
Yes    

No

Stroke:
Yes    

No

Surgical implant:
Yes    

No

Swelling of feet or ankles:
Yes    

No

Thyroid disease or malfunction:
Yes    

No

Tobacco habit:
Yes    

No

Tonsillitis:
Yes    

No

Tuberculosis:
Yes    

No

Ulcer/Colitis:
Yes    

No

Venereal disease:
Yes    

No

Is patient currently taking any medications? If yes, list all:
Does patient have drug allergies? If yes, list all:

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 the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I 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.