NEW PATIENT FORM

Patient Information

Name

First Middle Initial Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Email

Sex

Male
Female

Marital Status

Birthdate

Age

Patient Employed By

Occupation

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone

Business Email

Whom may we thank for referring you?

Notify incase of emergency

Name

First Last

Home Phone

Cell Phone

Business Phone

Email

Primary Insurance

Person Responsible For Account

First Middle Initial Last

Relation to Patient

Birthdate

Is address different from patient?

Yes
No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Email

Person Responsible Employed By

Occupation

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone

Business Email

Insurance Company

Insurance Phone

Insurance Email

Contract #

Group #

Subscriber #

Name of other dependents under this plan

Additional Insurance

Is patient covered by additional insurance?

Yes
No

Subscriber Name

First Last

Relation to Patient

Birthdate

Is address different from patient?

Yes
No

Subscriber Employed By

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Email

Business Phone

Business Email

Insurance Company

Insurance Phone

Insurance Email

Contract #

Group #

Subscriber #

Name of other dependents under this plan

Dental History

What would you like us to do today?

Are you in dental discomfort today?

Former Dentist

Dentist Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dentist Email

Dentist Phone

Date of last dental care

Date of last x-rays

Check any of the following you have had problems with:

How often do you brush your teeth?

How often do you floss?

How do you feel about the appearance of your teeth?

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?

Yes
No

Other information about your dental health or previous treatment

Medical History

Physician’s name

Physician’s Phone

Date of last visit

Have you had any serious illnesses or operations?

Yes
No

Describe

Are you currently under physician care?

Yes
No

Describe

Have you ever had a blood transfusion?

Yes
No

Give approximate dates

Have you ever taken Fen-Phen/Redux?

Yes
No

Have you ever used a bisphosphonate medication?

Brand names include Fosamax, Actonel, Atelvia, Dridronel and Boniva

Yes
No

Are you a women?

Yes
No

Are you pregnant?

Yes
No

Are you nursing?

Yes
No

Are you taking birth control pills?

Yes
No

Check any of the following you have had:

Describe your heart problems

Is patient currently taking any medications? If yes, list all:

Does patient have allergies? If yes, list all:

Authorization

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is a change in my medical status, I will inform the dentist.

I authorize the insurance company indicated on this form to pay the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payments of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature

Date

Payment is due in full at the time of treatment, unless prior arrangements have been approved.

Patient Information

Notify incase of emergency

Primary Insurance

Additional Insurance

Dental History

Medical History

Authorization

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