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Patient Information

First Name Middle Initial Last Name
Address City State Zip Code

Social Security #
Sex: Male Female Birthday Single Married Widowed Separated Divorced

Patient Employed By Occupation
Business Address Business Phone

Whom may we thank for referring you?
Notify in case of emergency
Home Phone Work Phone

Primary Insurance

Person Responsible for Account
First NameMiddle Initial Last Name
if same as patient, leave blank
Address City State Zip Code

Relation to Patient
Social Security # Birthday Home Phone

Person Responsible Employed By
Occupation
Business Address
Business Phone

Insurance Company Insurer's Phone
Contract # Group # Subscriber #

Name of other dependents under this plan

Additional Insurance

Is Patient covered by additional insurance? Yes No

Additional insurance subscriber
First Name Middle Initial Last Name
if same as patient, leave blank
Address City State Zip Code

Relation to Patient Social Security # Birthday Home Phone

Subscriber Employed By
Business Phone

Insurance Company
Insurer's Phone
Contract # Group # Subscriber #

Name of other dependents under this plan

Dental History

What would you like us to do today?
Former Dentist Address
City State Zip Code Phone
Date of last dental care Date of last x-rays

Have you had problems with any of the following:

Bad Breath
Bleeding Gums
Clicking or popping jaw

Food collection between teeth
Grinding or clenching teeth
Loose teeth or broken fillings

Periodontal treatment Sensitivity to cold
Sensitivity to hot

Sensitivity to sweets
Sensitivity when biting
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? Yes No
Other information about your dental health or previous treatment?

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
Women: Are you pregnant? Yes No     •     Nursing Yes No     •     Taking birth control pills? Yes No

Have you have had any of the following:

AIDS
Anaphylaxis
Anemia
Arthritis, Rheumatism
Artificial heart valves
Artificial joints
Asthma
Atopic (allergy prone)
Back problems
Blood disease
Cancer
Chemical dependency
Chemotherapy
Circulatory problems
Cortisone treatments

Cough, persistent
Cough up blood
Diabetes
Epilepsy
Fainting
Food allergies
Glaucoma
Headaches
Heart murmur
Heart problems
Describe

Hemophilia/Abnormal bleeding

Herpes
Hepatistis
High blood pressure
Jaw pain
Kidney disease or malfunction
Liver disease
Material allergies (latex, wood.
metal, chemicals)
Mitral valve prolapse
Nervous problems
Pacemaker/Heart surgery
Psychiatric care
Rapid weight gain or loss
Radiation treatment
Respiratory disease

Rheumatic/Scarlet fever
Shingles
Shortness of breath
Skin rash
Spina Bifida
Stroke
Surgical implant
Swelling of feet or ankles
Thyroid disease or malfunction
Tobacco habit
Tonsillitis
Tuberculosis
Ulcer/Colitis
Veneral 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 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 finacially responsible for all charges whether or not paid by insurance.

Email address
For security, tell us your mother's maiden name

Payment is due in full at time of treatment, unless prior arrangements have been approved.