Date

SS/HIC/Patient ID #

Patient Name

Last name

First name

Middle Initial

Address

Email

City

State

Zip

Sex

Male

Female

Age

Patient Birthdate

Status

Married

Widowed

Single

Minor

Separated

Divorced

Partnered

Partnered for (Years)

Patient Employer/ School

Occupation

Employer/School Address

Employer/School Phone

Spouse's Name

Spouse Birthdate

SS#

Spouse's Employer

Whom may we thank for referring you

Dental Insurance

Who is responsible for this account?

Relationship to patient

Insurance Co.

Group #

Is patient covered by additional insurance?

Yes

No

Subscriber's Name

Birthdate

SS#

Relationship to Patient

Insurance Co.

Group#

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

Name of Insurance Company(ies)

and assigned 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 authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Name of Patient Parent Guardian or Personal Representative

Date

Relationship to Patient

Phone Numbers

Home

Work

Ext

Cell Phone

Spouse's Work

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT

Specify someone who does not live in your household.

Name

Relationship

Home Phone

Work Phone

Dental History

Reason for today's visit

Former Dentist

City/State

Date of last dental visit

Date of last dental X-rays

Please check Yes or No to indicate if you have had any of the following:

Bad breath

Yes

No

Bleeding gums

Yes

No

Blisters on lips or mouth

Yes

No

Burning sensation on tongue

Yes

No

Chew on one side of mouth

Yes

No

Cigarette, pipe or cigar smoking

Yes

No

Clicking or popping jaw

Yes

No

Dry mouth

Yes

No

Fingernail biting

Yes

No

Food collection between the teeth

Yes

No

Foreign objects

Yes

No

Grinding teeth

Yes

No

Gums swollen or tender

Yes

No

Jaw pain or tiredness

Yes

No

Lip or cheek biting

Yes

No

Loose teeth or broken fillings

Yes

No

Mouth breathing

Yes

No

Mouth pain, brushing

Yes

No

Orthodontic treatment

Yes

No

Pain around ear

Yes

No

Periodontal treatment

Yes

No

Sensitivity to cold

Yes

No

Sensitivity to heat

Yes

No

Sensitivity to Sweets

Yes

No

Sensitivity when biting

Yes

No

Sores or growths in your mouth

Yes

No

How often do you floss?

How often do you brush?

Health History

Physician's Name

Date of last visit

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Yes

No

Please mark Yes or No to indicate if you have had any of the following

AIDS/HIV

Yes

No

Anemia

Yes

No

Arthritis, Rheumatism

Yes

No

Artificial Heart Valves

Yes

No

Artificial Joints

Yes

No

Asthma

Yes

No

Back Problems

Yes

No

Bleeding abnormally, with extractions or surgery

Yes

No

Blood Disease

Yes

No

Cancer

Yes

No

Chemical Dependency

Yes

No

Chemotherapy

Yes

No

Circulatory Problems

Yes

No

Congenital Heart Lesions

Yes

No

Cortisone Treatments

Yes

No

Cough, persistent or bloody

Yes

No

Diabetes

Yes

No

Emphysema

Yes

No

Do you wear contact lenses?

Yes

No

Epilepsy

Yes

No

Fainting or dizziness

Yes

No

Glaucoma

Yes

No

Headaches

Yes

No

Heart Murmur

Yes

No

Heart Problems

Yes

No

Hepatitis

Yes

No

Type

Herpes

Yes

No

High Blood Pressure

Yes

No

Jaundice

Yes

No

Jaw Pain

Yes

No

Kidney Disease

Yes

No

Liver Disease

Yes

No

Low Blood Pressure

Yes

No

Mitral Valve Prolapse

Yes

No

Nervous Problems

Yes

No

Pacemaker

Yes

No

Pshychiatric Care

Yes

No

Radiation Treatment

Yes

No

Respiratory Disease

Yes

No

Rheumatic Fever

Yes

No

Scarlet Fever

Yes

No

Shortness of Breath

Yes

No

Sinus Trouble

Yes

No

Skin Rash

Yes

No

Special Diet

Yes

No

Stroke

Yes

No

Swollen Feet or Ankles

Yes

No

Swollen Neck Glands

Yes

No

Thyroid Problems

Yes

No

Tonsillitis

Yes

No

Tuberculosis

Yes

No

Tumor or growth on head or neck

Yes

No

Ulcer

Yes

No

Venereal Disease

Yes

No

Weigh Loss, unexplained

Yes

No

Women:

Are you pregnant?

Yes

No

Due Date

Are you nursing ?

Yes

No

Taking birth control pills?

Yes

No

Medications

List any medications you are currently taking and the correlating diagnosis:

Diagnosis

Pharmacy Name

Phone

Allergies

Aspirin

Barbiturates (Sleeping pills)

Codeine

lodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

Which?

Updates

Had there been any change in your health since your last dental appointment?

Yes

No

For what conditions?

Are you taking any new medications?

If so what?

Date

E-Signature

Please sign electronically below.

Patient Information

Dental Insurance

ASSIGNMENT AND RELEASE

Phone Numbers

IN CASE OF EMERGENCY, CONTACT

Dental History

Health History

Please mark Yes or No to indicate if you have had any of the following

Women:

Medications

Allergies

Updates

E-Signature