Welcome

ABOUT YOU

INSURANCE

Today's Date: / /
                      mm / dd /  yyyy
Personal Email:
Work Email:
Last Name:
First Name: Middle:
Preferred Name: Male Female
Birth date:
/ /  
                  mm /  dd /  yyyy
Social Security: --
Home Address:  
City: State: Zip:

Single Married Divorced Widowed Separated
Home Phone #:  --
Pager/Cellular #: --
Work Phone #:-- Ext:
Employer:
Employer's Address:  
City: State: Zip:
How Long there?: month years 
Occupation:
What are best ways to reach you? 
home work  am pm
Previous/Present Dentist:

                                        Primary Insurance

Dental Coverage? Yes No 
Medical Coverage? Yes No
Insurance Co. Name: 

Insurance Co.  Address:

City: State: Zip:
Group #:
Insured's Last Name:
First Name: Middle:
Birth date: / /
                  mm / dd / yyyy
Social Security:--
Employer's Address:
City: State: Zip:

                                        Secondary Insurance

Dental Coverage? Yes No 
Medical Coverage? Yes No
Insurance Co. Name: 

Insurance Co.  Address:
City: State: Zip:
Group #:

Insured's Last Name:
First Name: Middle:
Birth date: / /
                 mm / dd / yyyy
Social Security:--
Employer's Address:
City: State: Zip:

SPOUSE INFORMATION

Last Name:
First Name: Middle:
Birth date: / /
                  mm / dd /  yyyy 
Social Security: --
Home Phone #:  --  
Pager/Cell #: --  
Work Phone #:-- Ext:
Personal Email:
Work Email:
Employer:  
Previous/Present Dentist:
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform will be  


___________________________________ Date:__________  
Relationship to Patient____________________________
Signature of patient, parent or guardian

I certify that I am covered by _______________________ Insurance company and I assign directly to Dr. _________________________ all insurance benefits, otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

Signature___________________________ Date:___________

REFERRAL INFORMATION

Whom may we thank for referring you to our practice? Another patient- friend Another patient- relative Dental Office Yellow Pages Newspaper School Work Internet Search Online dental directory Online insurance dental directory
Name of the person or office referring you to our practice?
Other family members seen by us:

MEDICAL HISTORY

DENTAL HISTORY

Do you have a personal physician? Yes No
Physician's Name:
Phone #:--  
Date of Last Visit: / /
                             mm / dd / yyyy
Your current physical health is:  
Good Fair Poor

Are you currently under the care of a physician? Yes No
Please explain:
Do you smoke or use tobacco in any other form?Yes No
Have you had any metal rods, pins or implants? Yes No
Date of Last Dental Visit: / /
                                  mm / dd / yyyy
Reason for this visit:
Are you currently in pain? Yes No
Do you require antibiotics before dental treatment? Yes No
Your current dental health is:  
Good Fair Poor

Have you ever had a serious/difficult problem associated with any previous dental work? Yes No
Do you floss daily? Yes No Brush daily? Yes No
Type of bristles on your toothbrush?
Hard Medium Soft
How long do you use a toothbrush before replacing it?

Have you ever had gum treatment? Yes No
Do your gum ever bleed? Yes No 
Ever Itch? Yes No 
Have you ever had periodontal disease? Yes No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? Yes No
Are your teeth sensitive to heat, cold, or anything else?
YesNo
Do you have mobility in your teeth? Yes No
Do you still have any wisdom teeth? Yes No
Would you like fresher breath? Whiter teeth? Yes No
Are you happy with the way your smile looks? Yes No
If not, what would you change? 
For Women: Are you taking birth control pills? Yes No
Are you pregnant? Yes No  Week #:
Are you nursing? Yes No
Are you allergic to any of the following?
Aspirin
Barbiturates
Codeine
Dental Anesthetics
Erythromycin
Jewelry/Metals
Latex
Penicillin
Sedatives
Sulfa Drugs
Tetracycline
Other
List additional drugs/materials that cause allergic reactions: 

Are you taking any of the following?

Acetaminophen
Antibiotics
Antihistamines
Aspirin
Blood Thinners
Blood Pressure Medication
Cold Remedies
Digitalis/Heart Medication
Insulin/Diabetes Drugs
Nitroglycerin
Recreational Drugs
Steroids/
Cortisone
Thyroid Medicine
Tranquilizers
Are you taking any prescription/over-the-counter-drugs not listed above? Yes No

Have you ever had any of the following diseases or medical problems?

Abnormal Bleeding
Alcohol Abuse
Anemia
Arthritis
Artificial Bones/Joints
Artificial Valves
Asthma
Blood Transfusion
Cancer
Chemotherapy
Chicken Pox
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Fainting Spells
Fever Blisters
Glaucoma
Hay Fever
Headaches
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis
Herpes
High Blood Pressure
HIV+/AIDS
Hospitalized for Any Reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Value Prolapse
Pacemaker
Persistent Cough
Psychiatric Problems
Radiation Treatment
Rheumatic Fever
Scarlet Fever
Seizures
Shingles
Sickle Cell Disease
Sinus Problems
Steroid Therapy
Stroke
Thyroid Problems
Tonsillitis
Tuberculosis (TB)
Ulcers
Venereal Disease
Please list any serious medical condition (s) that you have experienced:
To the best of my knowledge all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

_______________________________________________________Date:_______________________
Signature of patient, parent or guardian

_______________________________________________________Date:_______________________
Dr. Signature

Copyright 2001bizdecisionpoint.com