Patient Information Form

Patient Information

* Patient Name: (Required)

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Driver's License Number:

Social Security Number:

Gender: Male Female

Marital Status: Single Married Other

Phone Number:

Phone Type home cell office

E-mail:

Employer's Name:

Occupation:

Spouse / Partner Information

Spouse/Partner's Name:

Social Security Number:

Birth Date:

Driver's License Number:

Address (if different than patient):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell office

Insurance Information

Primary Insurance

Policy Holder's Name:

Policy Holder's SSN:

Primary Insurance Company:

Employer:

Group Number:

Policy Holder's Date of Birth:

Secondary Insurance

Policy Holder's Name:

Policy Holder's SSN:

Primary Insurance Company:

Employer:

Group Number:

Policy Holder's Date of Birth:

General Information

Convenient Appointment Time

Time Of Day

Are You Available For Appointment On Short Notice

Person To Contact In Case Of Emergency

Their Phone Number

Medical History

Are you currently being treated by a physician? Yes No

Reason:

Physician:

Last Visit:

Phone:

Do you have any allergies/sensitivities to medications or latex? Yes No

If yes, please list:

Are you currently taking any prescription or over-the-counter medications? Yes No

If yes, please list with the dosage:

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes No

Have you ever been hospitalized? Yes No

If yes, please explain:

Do you wear a Cardiac Pacemaker? Yes No

Do You Have Other Disease, Fainting Problem Or Condition That You Think The Doctor Should Know About? Yes No

If yes, please explain:

Dental History

How Long Since You've Been To The Dentist?

Have Your Ever Had An Unfavorable Experience With A Dentist?

Is There Anything We Can Do To Make You Feel More Comfortable While Receiving Treatment? Nitrous Oxide Stereo Headphones Other

When Were Your Last Set of X-Rays Taken?

Disease Problems Or Condition That You Have Been Instructed In The Care Of Your Gums?

Have You Ever Been Treated For Periodontal (Gum) Disease? Yes No

Do You Have Any Sores, Blisters, Or Swelling On Your Gums, Lips Or Cheeks? Yes No

If Yes, Please Explain

Do You Grind Or Clench Your Teeth? Yes No

Have Your Ever Had Popping Or Clicking Near Your Ear When You Chew? Yes No

Have You Had Orthodontic Treatment? Yes No

Do You, Or Have You Had Any Dental Disease Problems Or Condition That Hasn't Been Mentioned? Yes No

Please Explain

Authorization

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I attest to the accuracy of the information on this form.

Submitted by:

Date: