Welcome

The benefits of a happy healthy smile are immeasureable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we care for you.

1. About You

Today's Date: Email Address:
Name:
I prefer to be called: Male Female
Birthdate: Age: SS#:
Home Address:
Single Married Divorced/Separated Widowed
Hm. # Pager/Other #
Wk. # (incl. Ext.) DL #
Employer:
Employer's Address:
How long there? Occupation:
When and where are the best times to reach you?
Who may we thank for referring you?
Other family members seen by us:
Previous/Present Dentist:
Last visit date:

2. Spouse Information

His/Her Name:
Employer:
Wk # (incl. ext): SS #:
Birthdate: Driver's License #:
Person Responsible for Account:
Wk # (incl. ext): Home #:
Billing Address:
Relation: SS #:
Employer: DL #:

3. Insurance Coverage

Primary
Dental Coverage: Yes No Medical Coverage: Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group #(Plan, Local or Policy #):
Insured's Name: Relation:
Insured's Birthdate: Insured's SS #:
Insured's Employer:
Secondary
Dental Coverage: Yes No Medical Coverage: Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group #(Plan, Local or Policy #):
Insured's Name: Relation:
Insured's Birthdate: Insured's SS #:
Insured's Employer:
In the event of an emergency, is there someone who lives near you that we could contact?
His/Her name: Relation:
Work #: Hm #:

4. Medical History

Do you have a personal Physician? Yes or No
Physician's Name:
Your current physical health is: Good or Fair or Poor
Are you currently under the care of a Physician? Yes or No
Please explain:
Are you taking any prescription drugs? Yes or No
Please list each one:
Do you smoke or use tobacco in any other form? Yes or No
For Women: Are you taking birth control pills? Yes or No
Are you pregnant? Yes or No Week #:
Are you nursing? Yes or No

Have you ever had any of the following diseases or medical problems?
Y N Abnormal Bleeding Y N Hepatitis
Y N Alcohol/Drug Abuse Y N Herpes/Fever Blisters
Y N Anemia Y N High Blood Pressure
Y N Arthritis Y N HIV or AIDS
Y N Artificial Bones/Joints/Valves Y N Hospitalized for any reason
Y N Asthma Y N Kidney Problems
Y N Blood Transfusion Y N Liver Disease
Y N Cancer/Chemotherapy Y N Low Blood Pressure
Y N Calitis Y N Mitral Valve Prolapse
Y N Congenital Heart Disease Y N Pacemaker
Y N Diabetes Y N Psychiatric Problems
Y N Difficulty Breathing Y N Radiation Treatment
Y N Emphysema Y N Rheumatic/Scarlet Fever
Y N Epilepsy Y N Seizures
Y N Fainting Spells Y N Shingles
Y N Frequent Headaches Y N Sickle Cell Disease/Traits
Y N Glaucoma Y N Sinus Problems
Y N Hay Fever Y N Stroke
Y N Heart Attack Y N Thyroid Problems
Y N Heart Murmur Y N Tuberculosis/TB
Y N Heart Surgery Y N Ulcers
Y N Hemophiliac Y N Venereal Disease
Please list any serious medical conditions that you have ever had:
Are you allergic to any of the following?
Y N Aspirin Y N Codeine Y N Dental Anesthetics
Y N Erythromycin Y N Jewelery Y N Latex
Y N Metals Y N Penicillin Y N Tetracycline
Please list any other materials that you are allergic to:

5. Dental History

Why have you come to the dentist today?
Do you require antibiotics before dental treatment? Yes or No
Are you currently in pain? Yes or No
Have you ever had a serious/difficult problem associated
with any previous dental work? Yes or No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? Yes or No
Your current dental health is: Good or Fair or Poor
Do you like your smile? Yes or No
Would you like whiter teeth? Yes or No Fresher breath? Yes or No
Do your gums ever bleed? Yes or No
How many times a week do you floss? a day do you brush?
Type of bristles? Soft or Medium or Hard

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information 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 my dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
Signature________________________________ Date____________________
Payment is due in full at the time of the treatment unless prior arrangements have been approved.

If this office accepts insurance, I understand that I am responsible for payment of services renderedand also responsible for paying any copayment and deductiblesthat my insurance does not cover.
Signature________________________________ Date____________________
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

*OFFICE USE ONLY*OFFICE USE ONLY*OFFICE USE ONLY*
I verbally reviewed this medical Dental information above with the patient named herein.
initials_____ date______
Doctor's Comments:________________________________________________________________
__________________________________________________________________________________
1. Date:________ Comments:_______________________________ Signature:_______________
2. Date:________ Comments:_______________________________ Signature:_______________
3. Date:________ Comments:_______________________________ Signature:_______________