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Patient Information

Date(Required)

MM slash DD slash YYYY

SS/HIC/Patient ID #(Required)

Name(Required)

First Name Last Name

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sex

Male

Female

Age(Required)

Birthdate(Required)

MM slash DD slash YYYY

Marital Status(Required)

Married

Widowed

Single

Minor

Separated

Divorced

Partnered

For how many years?

Please enter a number less than or equal to 100.

Patient Employer/School

Occupation

Employer/School Address

Employer/School Phone

Spouse's Name

Birthdate

MM slash DD slash YYYY

SS/HIC/Patient ID #

Spouse’s Employer

Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account?(Required)

Relationship to Patient(Required)

Insurance Co.(Required)

Group #(Required)

Is patient covered by additional insurance?(Required)

Yes

Subscriber’s Name

Birthdate

MM slash DD slash YYYY

SS#

Relationship to Patient

Insurance Co.

Group #

ASSIGNMENT AND RELEASE

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Name of Insurance

This field is hidden when viewing the form

Dentist Name

I certify that I, and/or my dependent(s), have insurance coverage with [name of insurance company(ies)] and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative(Required)

Please print name of Patient, Parent, Guardian or Personal Representative(Required)

Birthdate

MM slash DD slash YYYY

Relationship to Patient

Phone Numbers

Phone

Work

Cell

Spouse’s Work

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household)

Name

Full Name

Relationship

Home Phone

Work Phone

Dental History

Reason for your visit today?

Former Dentist

City/State

Date of last dental visit

MM slash DD slash YYYY

Date of last dental X-rays

MM slash DD slash YYYY

Place a mark on “yes” or “no” to indicate if you have had any of the following:

Bad breath

Yes

Bleeding gums

Yes

Blisters on lips or mouth

Yes

Burning sensation on tongue

Yes

Chew on one side of mouth

Yes

Cigarette, pipe or cigar smoking

Yes

Clicking or popping jaw

Yes

Dry mouth

Yes

Fingernail biting

Yes

Food collection between the teeth

Yes

Foreign objects

Yes

Grinding teeth

Yes

Gums swollen or tender

Yes

Jaw pain or tiredness

Yes

Lip or cheek biting

Yes

Loose teeth or broken fillings

Yes

Mouth breathing

Yes

Mouth pain, brushing

Yes

Orthodontic treatment

Yes

Pain around ear

Yes

Periodontal treatment

Yes

Sensitivity to cold

Yes

Sensitivity to heat

Yes

Sensitivity to sweats

Yes

Sensitivity when biting

Yes

Sores or growths in your mouth

Yes

How often do you floss?

How often do you brush?

Health History

Physician's Name

Date of last visit

MM slash DD slash YYYY

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.

Yes

Have you ever taken any of the group of drugs collectively referred to as “fen-phen”? These include combinations of lonimin,Adipex, Fasting (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)

Yes

Place a mark on “yes” or “no” to indicate if you have had any of the following:

AIDS/HIV

Yes

Anemia

Yes

Arthritis, Rheumatism

Yes

Artificial Heart Valves

Yes

Artificial Joints

Yes

Asthma

Yes

Back Problems

Yes

Bleeding abnormally, with extractions or surgery

Yes

Blood Disease

Yes

Cancer

Yes

Chemical Dependency

Yes

Chemotherapy

Yes

Circulatory Problems

Yes

Congenital Heart Lesions

Yes

Cortisone Treatments

Yes

Cough, persistent or bloody

Yes

Diabetes

Yes

Emphysema

Yes

Epilepsу

Yes

Fainting or dizziness

Yes

Glaucoma

Yes

Headaches

Yes

Heart Murmur

Yes

Heart Problems

Yes

Hepatitis

Yes

Herpes

Yes

Select Hepatitis Type(Required)

Hepatitis A

Hepatitis B

Hepatitis C

Hepatitis D

Hepatitis E

High Blood Pressure

Yes

Jaundice

Yes

Jaw Pain

Yes

Kldney Diseaве

Yes

Liver Disease

Yes

Low Blood Pressure

Yes

Mitral Valve Prolapse

Yes

Nervous Problems

Yes

Pacemaker

Yes

Psychiatric Care

Yes

Radiation Treatment

Yes

Respiratory Disease

Yes

Rheumatic Fever

Yes

Scarlet Fever

Yes

Shortness of Breath

Yes

Sinus Trouble

Yes

Skin Rash

Yes

Special Diet

Yes

Stroke

Yes

Swollen Feet or Ankles

Yes

Swollen Neck Glands

Yes

Thyroid Problems

Yes

Tonsillitis

Yes

Tuberculosis

Yes

Tumor or growth on head or neck

Yes

Ulcer

Yes

Venereal Disease

Yes

Weight Loss, unexplained

Yes

Do you wear contact lenses?

Yes

Women:

Are you pregnant?

Yes

Due Date

MM slash DD slash YYYY

Are you nursing?

Yes

Taking birth control pills?

Yes

Medications

List any medications you are currently taking and the correlating diagnosis:

Allergies

Are you allergic to any of the following?

Aspirin

Barbiturates (Sleeping pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

Other allergies or reactions

Pharmacy Name

Phone

Updates

Has there been any change in your health since your last dental appointment?

Yes

For what conditions?

Are you taking any new medications?

Yes

If so, what?

Patient’s Signature(Required)

Date(Required)

MM slash DD slash YYYY

+1 (239) 997-9949

Dental Registration & History

Patient Information

Dental Insurance

Phone Numbers

Dental History

Health History

Medications

Allergies

Updates