Confidential Patient Information

* First Name:
MI:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Social Security #:

If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any family members we have also treated:
List any sports, hobbies, or musical instruments played:
* Whom may we thank for referring you to our practice?
If referrer is Family/Friend or Other, please be specific:

Financial Party Information

* First Name:
MI:
* Last Name:
Marital Status:
Relationship to Patient:
* Birthdate:
* Address:
* City:
* State:
* Zip:
Email:
* Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:

Spouse or Other Parent's First Name:
MI:
Last Name:
Relationship to Patient:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

* I Have Dental Insurance
     (If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Subscriber ID #:
Subscriber SSN:
Birthdate:
Group No.:
Insurance Company:
Insurance Co. Phone No.:
Insurance Co. Address:
City:
State:
Zip:
Do you have dual dental coverage?
     (If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Subscriber ID #:
Subscriber SSN:
Birthdate:
Group #:
Insurance Company:
Insurance Co. Phone No.:
Insurance Co. Address:
City:
State:
Zip:

Dental History

Dentist Name:
Name of Practice:
Dentist Address:
Check-up Frequency:
Last Dental Visit:

Medical History

* Has there been any change in the patient's general health within the last year?
* Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
* Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
* Latex
* Penicillin or other antibiotics
* Sulfa drugs
* Aspirin, Ibuprofen, Tylenol
* Local anesthetics
* Metal Allergy
* Peanut/Nut
* Seasonal
* Food
* Other:
List any drug allergies or sensitivities (not listed above) that the patient may have:

All answers default to NO. Please select YES if the patient has had any of the conditions listed below either now or in the past.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia / Blood disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis / Joint problems
Large Tonsils
Sinus trouble
Substance abuse problem (past or present)
Bone fractures/trauma to face/jaw
Prosthetic joints
Chronic fatigue
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Received Radiation Treatment
Arteriosclerosis
Thyroid / Endocrine Problems
Stomach ulcer or hyperacidity
Hormone Therapy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory problems / Emphysema
Persistent swollen neck glands
Low blood pressure
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes', please explain:
Dental Specific Anxiety or Fears:
Is there anything else we should know about the patient to ensure a great experience at our office?
* Signature of patient if over 18 or parent/legal guardian: