Basic Info
*First Name:
MI:
*Last Name:
*D.O.B.:
*SSN#
Drivers License:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
How would you like to recieve appointment reminders? (Check applicable)
Home Phone Call
Cell Phone Call
Cell Phone Text
Email
What school does patient attend? (If applicable)
Patient hobbies or interests?
Who may we thank for referring you?
Mail
Insurance
Billboard
Dentist
Friend/Family:
Other:
Parent/Guardian Info
*First Name:
*Last Name:
Relationship to Patient
D.O.B.
SSN #
Driver's License #
Address same as Patient's
*Address:
*City:
*State:
*Zip:
Home Phone
Cell Phone
Insurance Info
Insurance Company
Insured's Name
Insured D.O.B.
Insured's SSN#
Subscriber ID
Group Number
Employer
Insurance Co. Address:
City:
State:
Zip:
Emergency Contact
First Name
Last Name
Relation to the Patient
Address
City
State
Zip Code
Home Phone
Cell Phone
Dental History
Dentist Name
When was the patient's last dental exam and cleaning?
If you go to a chain (ex. Perla, Monarch, Etc) please list city
Phone Number
Medical History
Physician Name
Phone Number
Date of last visit
Currently under a physician's care?
Yes
No
Is patient currently taking medication?
Yes
No
If yes, please list medications
Is patient allergic to any medications?
Yes
No
If yes, please list allergies
Has patient had any major accidents or surgery?
Yes
No
If yes, please list
Has the patient ever been premedicated prior to dental treatment?
Yes
No
If yes, please list
Has the patient had any of the following (please select 'Yes' or 'No' for each)
Anemia
Yes
No
Bone Disorders
Yes
No
Blood Disease
Yes
No
Epilepsy
Yes
No
Prolonged Bleeding
Yes
No
Herpes or Venereal Disease
Yes
No
Hepatitis
Yes
No
Emotional Distress
Yes
No
AIDS or HIV Positive
Yes
No
Radiation Treatment
Yes
No
Jaundice
Yes
No
Tonsilitis
Yes
No
Malignancies, Tumors, Cancer
Yes
No
Mononucleosis
Yes
No
Rheumatic Fever
Yes
No
Asthma
Yes
No
Tonsils Removed
Yes
No
Adenoids Removed
Yes
No
Tonsils Removed at age
Adenoids Removed at age
Currently Smoking
Yes
No
Smokeless Tobacco
Yes
No
Heart Disease or Murmur
Yes
No
Mouth Breathing
Yes
No
Tuberculosis
Yes
No
Disability
Yes
No
Diabetes
Yes
No
Currently Pregnant
Yes
Endocrine Problems
Yes
No
How many months?
By checking this box, you agree that the information on this form is true and accurate to the best of your knowledge.