Patient Information Form Step 1 of 5 20% PhoneThis field is for validation purposes and should be left unchanged.Patient #Date Month Day Year Patient's Sex F M Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us - we will be happy to help. PATIENT INFORMATION (CONFIDENTIAL)NameBirthdate Month Day Year Home PhoneAddress Street Address City State/ Prov ZIP / Postal Code Email Cell Phone.Do you prefer to receive calls at your: Home Work Cell Phone Check Appropriate Box: Minor single Married Divorced Widowed Separated If Student, Name of School/College City State / Province / Region Full Time Part Time Patient or Parent/Guardian's EmployerWork PhoneBusiness Address Street Address City State/ Prov ZIP / Postal Code Spouse or Parent/Guardian's NameEmployerWork PhoneWhom may we thank for referring you?Person to contact in case of emergencyPhone RESPONSIBLE PARTYName of Person Responsible for this AccountRelationship to PatientAddressHome PhoneEmail Cell PhoneDriver's License#Birthdate Month Day Year Financial InstitutionEmployerWork PhoneIs this person currently a patient in our office? Yes No For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment. Cash Personal Check Credit Card VISA MasterCard I wish to discuss the office's payment policy. INSURANCE INFORMATIONName of InsuredRelationship to PatientBirthdate Month Day Year Date Employed Month Day Year Name of EmployerUnion or Local #Work PhoneAddress of Employer Street Address City State/ Prov ZIP / Postal Code Insurance CompanyGroup #Policy/ID #Ins. Co. Address Street Address City State/ Prov ZIP / Postal Code How much is your deductible?How much have you used?Max. annual benefitDO YOU HAVE ANY ADDITIONAL INSURANCE? Yes No IF YES, COMPLETE THE FOLLOWING:Name of InsuredRelationship to PatientBirthdate Month Day Year Date Employed Month Day Year Name of EmployerUnion or Local #Work PhoneAddress of Employer Street Address City State/ Prov ZIP / Postal Code Insurance CompanyGroup #PolicyID #Ins. Co. Address Street Address City State/ Prov ZIP / Postal Code How much is your deductible?How much have you used?Max. annual benefit PATIENT MEDICAL HISTORYPhysicianOffice PhoneDate of Last Exam Month Day Year 1. Are you under medical treatment now? Yes No 2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? Yes No If yes, what medication(s) are you taking3. Are you taking any medication(s) including non-prescription medicine? Yes No If yes, please explain4. Have you ever taken Fen-Phen/Redux? Yes No 5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates? Yes No 6. Have you taken Viagra, Revatio, Cialis or Levitro n the last 24 hours? Yes No 7. Do you use tobacco? Yes No 8. Do you use controlled substances? Yes No 9. Do you have or have you had any of the following?High Blood Pressure Yes No Heart Attack Yes No Rheumatic Fever Yes No Swollen Ankles Yes No Fainting / Seizures Yes No Asthma Yes No Low Blood Pressure Yes No Epilepsy / Convulsions Yes No Leukemia Yes No Diabetes Yes No Kidney Diseases Yes No AIDS or HIV Infection Yes No Thyroid Problem Yes No Heart Disease Yes No Cardiac Pacemaker Yes No Heart Murmur Yes No Angina Yes No Frequently Tired Yes No Anemia Yes No Emphysema Yes No Cancer Yes No Arthritis Yes No Arthritis Yes No Joint Replacement or Implant Yes No Hepatitis / Jaundice Yes No Hepatitis / Jaundice Yes No Sexually Transmitted Disease Yes No Stomach Troubles / Ulcers. Yes No Chest Pains Yes No Easily Winded Yes No Stroke Yes No Hay Fever / Allergies Yes No Tuberculosis Yes No Radiation Therapy Yes No Glaucoma Yes No Recent Weight Loss Yes No Liver Disease Yes No Heart Trouble Yes No Mitral Valve Prolapse Yes No Respiratory Problems Yes No Other Yes No Other 10. Are you wearing contact lenses? Yes No 11. Are you allergic to or have you had any reactions to the following?Local Anesthetics (e.g. Novocain) Yes No Penicillin or any other Antibiotics Yes No Sulfa Drugs Yes No Barbiturates Yes No Sedatives Yes No Iodine Yes No Aspirin Yes No Any Metals (e.g. nickel, mercury, etc.) Yes No Latex Rubber Yes No Other12. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)? Yes No 13. Women Only:a) Are you pregnant or think you may be pregnant? Yes No b) Are you nursing? Yes No c) Are you taking oral contraceptives? Yes No PATIENT DENTAL HISTORYName of Previous Dentist and LocationDate of Last Exam1. Do your gums bleed while brushing or flossing? Yes No 2. Are your teeth sensitive to hot or cold liquids/foods? Yes No 3. Are your teeth sensitive to sweet or sour liquids/foods Yes No 4. Do you feel pain to any of your teeth? Yes No 5. Do you have any sores or lumps in or near your mouth? Yes No 6. Have you had any head, neck or jaw injuries? Yes No 7. Have you ever experienced any of the following problems in your jaw?Clicking Yes No Pain (joint, ear, side of face) Yes No Difficulty in opening or closing Yes No Difficulty in chewing Yes No 8. Do you have frequent headaches? Yes No 9. Do you clench or grind your teeth? Yes No 10. Do you bite your lips or cheeks frequently? Yes No 11. Have you ever had any difficult extractions in the past? Yes No 12. Have you ever had any prolonged bleeding following extractions? Yes No 13. Have you had any orthodontic treatment? Yes No 14. Do you wear dentures or partials? Yes No If yes, date of placement15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums? Yes No 16. Do you like your smile?. Yes No AUTHORIZATION AND RELEASEPayment is due in full at the time of treatment unless prior arrangements have been approved This office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company. 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 the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.Signature of patient (or parent/guardian if minor)Your NameYour NameYour NameYour NameDate Month Day Year
