Adult

Patient Information

* Patient Name: (Required)

* I like to be called:

Gender: Male Female

Social Security Number:

Birth Date:

Age:

Home Address:

City:

State:

Zip:

Primary Phone Number:

Phone Type home cell

OK to leave message? Yes No

E-mail:

Employer's Name:

Occupation:

Special Interests, Sports or Hobbies:

Spouse / Partner Information

Social Security Number:

Birth Date:

Address (if different than patient):

City:

State:

Zip:

Primary Phone:

Phone Type: home cell

Secondary Phone:

Phone Type: home cell

Emergency Contact Information

Emergency Contact's Name:

Phone Number:

Relation to Patient:

Address:

City:

State:

Zip:

Person(s) OK to release appointment or medically-related information to:

Relation to Patient:

Insurance Information

Primary Insurance

Primary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Secondary Insurance

Secondary Insurance Company:

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Co-pay (if known):

Deductible (if known):

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN:

Policy Holder's Date of Birth:

Employer:

Work Phone Number:

Dental History

Have you ever had Orthodontic treatment (braces)? Yes No

Do you experience anxiety when you visit? Yes No

Previous Dentist:

Date of last exam, cleaning or x-rays:

Do you snore or have you ever been diagnosed with sleep apnea? Yes No

What are your chief concerns with your teeth?

Do your gums bleed when brushing or flossing? Yes No

Have you had a deep cleaning in the past (scaling and root planning)? Yes No

Do you like your smile? Yes No

If no, please explain:

Do you currently or have you ever had any of the following (check all that apply): Clenching/Grinding Teeth Cold Sensitivity Hot Sensitivity Pressure Sensitivity Food Trap

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 medication and reason:

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 had any serious illnesses or operations? If yes, describe:

Has a physician or previous dentist recommended that you premedicate before dental treatment (take antibiotics before your visit)? Yes No

If yes, give reason:

Authorization

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 of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

If you should find it necessary to reschedule your appointment, please do so within two (2) business days to avoid a late/missed cancellation fee.

I understand that where appropriate, credit bureau reports may be obtained.

Submitted by:

Date: