Gentle Family Dentistry- New Adult Patient Enrollment Form

New Patient Enrollment Form - Adults

Welcome To Our Family at Gentle Family Dentistry!
Patient Information
Please Choose Your Gentle Family Dentistry Location: *

Winslow Madison Augusta
Full Name *

First Name Middle Name Last Name
Nickname
If applicable
E-mail
Social Security # *
Date of Birth *

Month Day Year
Sex *

Male Female
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Cell #
Home #:
Work #:
Marital Status *

Single Married Separated Divorced Widowed
How Did You Hear About Us? *
Other family members seen by us:
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *
Primary Insurance Information
Do you have insurance? *

Yes No
Primary Insurance Carrier: *
Subscriber ID#: *
Group #: *
Insurance Phone Number *

Area Code Phone Number
Insurance Mailing Address: *

Street Address

Street Address Line 2

City State

Zip Code
Name of Insured: *

First Name Last Name
Employer Name: *
Insured's Birthdate: *

Month Day Year
Date
Insured's Social Security # *
Do you have Secondary Insurance? *

Yes No
Secondary Insurance Information
Secondary Insurance Carrier: *
Secondary Subscriber ID#: *
Secondary Group #: *
Secondary Insurance Phone Number *

Area Code Phone Number
Secondary Insurance Mailing Address: *

Street Address

Street Address Line 2

City State

Zip Code
Employer Name: *
Name of Insured: *

First Name Last Name
Insured's Birthdate: *

Month Day Year
Date
Insured's Social Security # *
Dental History
Are you currently experiencing any discomfort? *

Yes No
If Yes, Please Describe Your Pain or Discomfort *
Are you required to take antibiotics before a dental treatment? *

Yes No
Do your gums ever bleed? *

Yes No
Have you ever been told you have Periodontal Disease? *

Yes No
Please Rate Your Current Dental Health (choose one) *

Good Fair Poor
Do you Floss daily? *

Yes No
Do you Brush daily? *

Yes No
Which Type Of Bristles Do You Use? *

Hard Medium Soft
Are your teeth sensitive to heat, cold or anything else? *

Yes No
When Was Your Last Dental Visit? *

Less Than 6 Months Ago 6 to 12 Months Ago 12 to 18 Months Ago More Than 18 Months Ago
Are you happy with the way your smile looks? *

Yes No
If not, what would you change? *
Medical History
Primary Care Physician: *
Primary Care Physician Phone Number: *
Date Of Last Visit To Your Primary Care Physician *

Month Day Year
Date
Your current physical health is? (choose one) *

Good Fair Poor
Are you taking any prescriptions or over the counter medication? *

Yes No
If yes, please list it here *
Preferred Pharmacy Name: *
Preferred Pharmacy Location: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you smoke or use tobacco in any form? *

Yes No
If Yes, Please Describe Your Tobacco Use: *
Have you ever been told you snore or hold your breath while you sleep? *

Yes No
Have you ever taken Fosamax or any other Bisphosphonates? *

Yes No
Allergic to any of the following? (Select all that apply) *

No Known Allergies Aspirin Barbiturates Codeine Dental Anesthetics Erythromycin Jewelry/Metals Latex Mint Penicillin Sedatives Sulfa Drugs No Allergies Tetracycline Other
What are your other allergies we should know about? *
Are you taking any of the following? (Select all that apply) *

No Acetaminophen Antibiotics Antihistamines Blood Thinners Blood Pressure Medication Cold Medication Insulin/Diabetes Drugs Nitroglycerin Steroids/Cortisone Recreational Drugs Thyroid Medication Tranquilizers
Have you had any of the following diseases or medical problems? *

No Acid Reflux Alcohol Abuse Anemia Angina Artificial Bones/Joints Artificial Valves Asthma Blood Transfusion Cancer Chemo/Radiation Colitis Heart Congenital Heart Defect Diabetes Drug Abuse Emphysema Epilepsy/Seizures Glaucoma HIV+/AIDS Headaches Heart Attack Heart Murmur Heart Surgery/Pacemaker Hemophilia/Abnormal Bleeding Hepatitis Type A Hepatitis Type B Hepatitis Type C Hepatitis Type D Hepatitis Type E Herpes/Cold Sores High/Low Blood Pressure Kidney Problems Liver Disease Lupus Lyme Disease Mitral Valve Prolapse Psychiatric Treatment Rheumatic Fever Scarlet Fever Shingles Sinus Problems Stroke Thyroid Problems Tonsillitis Tuberculosis No I have not Ulcers Venereal Disease Other
What are the other diseases or medical problems we should know about? *
What was the date of your heart attack? *

Month Day Year
Date
For Women Only:
Are you taking birth control pills? *

Yes No
Are You Nursing? *

Yes No
Are You Pregnant? *

Yes No Unsure
If Yes, How many weeks along are you? *
Consent
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.

Payment is due at time of service unless prior arrangements have been made. I understand that I am responsible for payment of services rendered and also responsible of any copay and deductibles that my insurance does not cover.
Patient/Guardian (Type Name) *

First Name Last Name
Patient / Guardian Signature: (use mouse or finger to draw your signature) *

Clear
Date *

Month Day Year
Date
Should be Empty:

New Patient Enrollment Form - Adults

Patient Information

Primary Insurance Information

Secondary Insurance Information

Dental History

Medical History

For Women Only:

Consent