Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
Age:
*Gender:  
Marital Status:
*Address:  
*City:  
*State:  
*Zip:  
Village/Subdivision:
Name of school:
*Home Phone:  
Cell:
Email:
Social Security #:
Employer:
Grade:
Special interest, sports or hobbies:
Patient's Dentist:
Whom can we thank for this referral?
Dentist: (name)
Friends: (name)
Friends: (name)
Phone #:
   
Friends: (name)
Other: (name)
Family members who have been patients: (name & relationship)
Name of person accompanying child today:
Relationship:
  Siblings   
Name:
Birthdate:  
Gender:
Name:
Birthdate:  
Gender:
Name:
Birthdate:  
Gender:
Name:
Birthdate:  
Gender:
  Mother Information   
Name:
Birthdate:  
Address: (if different)
Home Phone:
Cell:
Work:
Email:
Social Security #:
Employer:
Marital Status:
  Father Information   
Name:
Birthdate:  
Address: (if different)
Home Phone:
Cell:
Work:
Email:
Social Security #:
Employer:
Marital Status:
  Person Responsible for Account   
*First Name:  
Middle Initial:
*Last Name:  
Birthdate:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
Cell:
Work:
Email:
Social Security #:
Employer:
  Primary Dental Insurance Information   
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:  
Relationship to Patient:
Group #:
ID# or SS#:
  Secondary Dental Insurance Information   
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:  
Relationship to Patient:
Group #:
ID# or SS#:
   Medical History     
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
  Heart Murmur/Congenital Defect
  Diabetes
  Rheumatic Fever
  Cancer
  HIV/AIDS
  Hemophilia
  Blood Transfusions
  Asthma
  Hepatitis
  Tuberculosis
  Heart Problems
  Sinus Problems
  Hypertension/High Blood Pressure
  Convulsions/Epilepsy
  Abdominal Bleeding
  Hearing Impairment
  Operations/Stays in a Hospital
  Kidney/Liver Problems
  Handicaps/Disabilities
  Allergies to Drugs, Metals, or Foods
  Antibiotics Prior to Dental Treatment
  Other Medical Problems
  Medications Phosphonates - ie. Fosomax, etc.
  Pregnant
If any of the above medical questions were answered 'Yes' , please explain:
  Dental History     
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
  Injuries to Face/Teeth
  Other Orthodontic Treatment
  Pain/Noises in the Jaw Joint (TMJ)
  Root Resorption
  Periodontal Disease
  Unfavorable Dental Experience
  Missing Teeth
  Extra Teeth
  Finger Sucking
  Tongue Thrusting
  Speech Problems
  Mouth Breathing
  Gums Bleed
  Grind Teeth
If any of the above dental questions were answered 'Yes', please explain:
What do you see as the main problem with your teeth?
I understand that the information that I have given today is correct to the best of myknowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.