Patient Information
*Patient's Name:
*Address:
*Home Ph:
Cell Ph:
Birthdate:
Mother's Name:
(if minor)
Father's Name:
(if minor)
Financial Party Information
*First Name:
Middle Initial:
*Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*Birthdate:
Address Same
*Address:
*City:
*State:
*Zip:
*
Own
Rent
How long at this address?
Previous Address (less than 3 years)
Email:
*Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:
*First Name:
Middle Initial:
*Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*Birthdate:
*Address:
*City:
*State:
*Zip:
How long at this address?
Previous Address (less than 3 years)
Email:
*Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:
Dental Insurance Information
Insured's Name:
Insured's Employer:
Insured's Social Security #:
Insured's Date of Birth:
Insurance Company:
Insurance Company Phone:
Insurance Company Address:
Group #:
Policy ID #:
Do you have secondary coverage?
Yes
No
Insured's Name:
Insured's Employer:
Insured's Social Security #:
Insured's Date of Birth:
Insurance Company:
Insurance Company Phone:
Insurance Company Address:
Group #:
Policy ID #:
Emergency Contact
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Medical History
Is the patient in good health?
Yes
No
If no, explain:
List any medications currently being taken by the patient (include non-prescription):
List any drug allergies or sensitivities:
Please select YES or No for the Following Questions - Do Not Leave Blank
Anemia
No
Yes
Arthritis
No
Yes
Asthma
No
Yes
Sleep Apnea
No
Yes
Bone Disorders
No
Yes
Diabetes
No
Yes
Epilepsy
No
Yes
Fainting/Dizziness
No
Yes
Headaches
No
Yes
Heart Trouble
No
Yes
Hepatitis
No
Yes
High Blood Pressure
No
Yes
HIV/AIDS
No
Yes
Neck Pain
No
Yes
Prolonged Bleeding
No
Yes
Rheumatic Fever
No
Yes
Dental History
Dentist Name:
Last Dental Exam:
Has the patient experienced:
Thumb/Finger sucking
No
Yes
Tongue thrusting
No
Yes
Popping/Clicking/Pain of jaw joint
No
Yes
Mouth breathing
No
Yes
Teeth grinding/clenching
No
Yes
Missing or extra permanent teeth
No
Yes
Gum disease
No
Yes
Have any permanent teeth been injured by a fall or blow?
No
Yes
Have tonsils and adenoids been removed?
No
Yes
I understand that where appropriate, credit bureau reports may be obtained.