New Patient Information

1. Patient Information

2. Dental Insurance

 Date: ex: 04/24/04
 Patient:
 Patient E-mail:
 Address:

City:

State:

Zip:

Sex:

Marital Status:

Age:

Birth Date:

                Patient SS#:
 Occupation:
 Employer:
 Employer Address:
 Employer Phone:
 Spouse's Name:

 Birthdate:

SS#:

                Occupation:
 Spouse's Employer:

 Whom may we thank for referring you?
 

 Who is responsible for this account?
 Relationship to Patient:
 Insurance Co:
 Group #:
 Is patient covered by additional insurance?
 Subscriber's Name:

Birthdate:

SS#:


 Relationship to Patient:
 Insurance Co:
 Group #:

ASSIGNMENT AND RELEASE (To be signed at office)
I, the undersigned certify that I (or my dependent) have insurance coverage with___________________________ and assign directly to Dr._____________________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submitions.

______________________________________________
Responsible Party Signature

________________________
Relationship

________________
Date

3. Phone Numbers

Home:

Cell:

Work:

Ext:

Spouse's Work:

                    Best time and place to reach you:
 IN CASE OF EMERGENCY, CONTACT:

Relationship:

Home Phone:

Work Phone:

4. Dental History

Reason for today's visit:

Clicking or popping jaw:

Pain around ear:

Former Dentist:

Dry mouth:

Periodontal treatment:

City/State:

Fingernail biting:

Sensitivity to cold:

Date of last dental visit:

Food collection between the teeth:

Sensitivity to heat:

Date of last dental x-rays:

Grinding teeth:

Sensitivity to sweets:

Click on "Yes" or "No" to indicate if you have had any of the following:

Gums swollen or tender:

Sensitivity when biting:

Bad breath:

Jaw pain or tiredness:

Sores or growths in your mouth:

Bleeding gums:

Lip or cheek biting:

How often do you floss?:

Blisters on lips or mouth:

Loose teeth or broken fillings:

How often do you brush?:

Burning sensation on tongue:

Mouth breathing:

Chew on one side of mouth:

Mouth pain, brushing:

Cigarette, pipe, or cigar smoking:

Orthodontic treatment:

5. Health History

Physicians's Name:

Date of last visit:


Click on"Yes" or "No" to indicate if you have had any of the following:

AIDS:

Glaucoma:

Psychiatric Care:

Anemia:

Headaches:

Radiation Treatment:

Arthritis, Rheumatism:

Heart Murmur:

Respiratory Disease:

Artificial Heart Valves:

Heart Problems:

Rheumatic Fever:

Artificial Joints:

Hepatitis

Scarlet Fever:

Asthma:

 (If yes) Type:

Shortness of Breath:

Back Problems:

Herpes:

Sinus Trouble:

Bleeding abnormally ,with extractions or surgery:

High Blood Pressure:

Skin Rash:

Blood Disease:

HIV Positive:

Special Diet:

Cancer:

Jaundice:

Stroke:

Chemical Dependency:

Jaw Pain:

Swelling of Feet or Ankles:

Chemotherapy:

Kidney Disease:

Swollen Neck Glands:

Circulatory Problems:

Liver Disease:

Thyroid Problems:

Congenital Heart Lesions:

Low Blood Pressure:

Tonsillitis:

Cortisone Treatments:

Mitral Valve Prolapse:

Tuberculosis:

Cough, persistent or bloody:

Nervous Problems:

Tumor or growth on head or neck:

Diabetes:

Pacemaker:

Ulcer:

Emphysema:

Women:

Venereal Disease:

Do you wear contact lenses?:

Are you pregnant?:

Unexplained Weight Loss:

Epilepsy:

(If yes) Due Date:

Fainting or dizziness:

Are you nursing?:

Medications

Allergies

List medications you are currently taking:

Pharmacy Name:
Phone:

Aspirin:

Local Anesthetic:

Barbiturates:

Penicillin:

Codeine:

Sulfa:

Iodine:

Other:

Latex:

Important: Before submitting this form please print a copy and take with you to your dental appointment!