*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Sex:
*Address:
*City:
*State:
*Zip:
*Home Phone:
Mother's Name:
(Patient under age of 18)
Father's Name:
(Patient under age of 18)
Name of any family members examined or treated in this office:
Name of general dentist:
Whom may we thank for referring you to our practice?

*First Name:
Middle Initial:
*Last Name:
Marital Status:
Relationship to Patient:
*Birthdate:
*Mailing Address:
*City:
*State:
*Zip:
How long at this address?
Email:
*Home Phone:
Cell Phone:
Work Phone:
Employer:
Occupation:
Length of Employment:

Spouse's First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Email:
Work Phone:
Cell Phone:
Policyholder's Name:
Relationship to Patient:
Policyholder's Birthdate:
Insurance Company:
Subscriber ID:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Policyholder's Employer:
Do you have dual dental coverage?
  (If yes, complete information below)

Policyholder's Name:
Relationship to Patient:
Policyholder's Birthdate:
Insurance Company:
Subscriber ID:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Policyholder's Employer:
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Physician Name:
Address:
City:
State:
Zip:

Is the patient now under the care of a physician? If yes, please explain:
Has the patient had a serious illness/hospitalization? If yes, please explain:   
List any medications or drugs (and dosages) that you are taking:

Are you allergic to:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Disease
Circulatory Problems
Heart Murmur
Rheumatic Fever
Congenital Heart Defect
Abnormal Blood Pressure
Diabetes
Epilepsy/Seizures
AIDS/HIV Positive
Abnormal Bleeding
Blood Transfusion
Prosthetic Implant
Hepatitis
Strep Throat
Herpes Simplex (cold sores)
Asthma
Back Problems
Arthritis
Fainting Spells
Eating Disorders
Headaches

  
Nervousness
Mental Health Care
Radiation Therapy
Sinus Trouble
Thyroid Problem
Tonsilitis
Tumors
Ulcers
Seasonal Allergies
(Hayfever)
Other
Have you ever been advised to be premedicated prior to dental treatment for any of the above conditions?
If yes, reason: