Patient Biographical Information    
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:  
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:

Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Dentist:
Date of last cleaning:
If patient is under the age of 18, please answer the following questions:
Parent 1 Information (Please check the appropriate box)     
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Work Phone #:
Parent 2 Information (Please check the appropriate box)     
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Work Phone #:
  Financial Party Information    
 
*First Name:
Middle Initial:
*Last Name:
Birthdate:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Employer:
Occupation:
Work Phone #:
  Dental Insurance Information    
Primary Insurance Information
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Birthdate:
Relationship to Patient:
Do you have dual dental coverage?   (If yes, complete information below)
Secondary Insurance Information
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Birthdate:
Relationship to Patient:
  Emergency Information    
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
   Medical History     
Patient Health:
List any medical conditions and medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
A recent physical exam
Any heart problems
High/Low blood pressure
Circulatory problems
Nervous problems
Radiation treatments
Pain in ear region
Excessive bleeding
Bleeding gums
Food collect between teeth
Anemia
Arthritis
Asthma
Cerebral palsy
Chicken pox
Chronic sinus
TMJ problems
Headaches
Neck aches
Back aches
Jaw Pain
Previous Orthodontic Treatment
Previous Date:
Mastoid/ear infection
Measles
Mumps
Kidney problems
Rheumatic fever
Scarlet fever
Thyroid
Tonsillitis
Tuberculosis
Hepatitis, Liver problems or Jaundice
Social Diseases
HIV positive
Diabetes
Epilepsy
Malignancies
Dental extractions (wisdom teeth)
Thumb/Finger Habit
Tongue Thrusting
Previous Periodontal Treatment
Previous Date:
Tooth Sensitivity (Select all that apply)
If any of the above medical questions were answered 'Yes' , please explain: