PATIENT INFORMATION FORM
Name
*
First Name
Middle Name
Last Name
Preferred Name
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Referred By
*
Birthday
*
/
Month
/
Day
Year
Date
Social Security Number
*
Employed By
*
Sex
*
Male
Female
Prefer Not to Say
Relationship Status
*
Single
Married
Divorced
Widowed
Other
Preferred Contact Number
*
Cell Phone
Home Phone
Work Phone
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
May we text your cell phone?
*
Yes
No
Is this application being filled out for a child?
*
Yes
No
Do you currently have DENTAL INSURANCE?
*
Yes
No
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DENTAL INSURANCE INFORMATION
We are not a Medicaid provider. We do NOT accept it as primary or secondary insurance.
PRIMARY DENTAL INSURANCE COMPANY
Please only provide details to your "dental" insurance, not medical.
Group Name
Group Number
*
Subscriber Name/Policy Holder
*
Subscriber ID or SSN
*
Subscriber DOB
*
/
Month
/
Day
Year
Date
Home Phone (if different)
Please enter a valid phone number.
Employed By
*
Business Phone
*
Please enter a valid phone number.
Address (if different from Patient)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
SECONDARY DENTAL INSURANCE COMPANY
(**OPTIONAL**)
Group Name
Group Number
Subscriber Name
Subscriber ID or SSN
Subscriber DOB
-
Month
-
Day
Year
Date
Home Phone (if different)
Please enter a valid phone number.
Employed By
Business Phone
Please enter a valid phone number.
Address (if different from Patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Person Responsible for Account Billing
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
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DENTAL HISTORY
Reason for Visit
*
Please Select
Routine Check-up
New Patient
Consultation
Emergency Visit
Date of Last Dental Visit
-
Month
-
Day
Year
Date
Would you like nitrous oxide for dental treatment? (additional charge)
*
Yes
No
Have you been diagnosed with periodontal (gum) disease?
*
Yes
No
Please describe your diagnosis on gum disease.
Do your gums bleed during brushing/flossing?
*
Yes
No
Please describe how your gums bleed during brushing/flossing.
Are you happy with the appearance of your teeth?
*
Yes
No
Please describe the appearance of your teeth or dislike.
Are your teeth sensitive to hot, cold, sweets, or pressure?
*
Yes
No
Please describe your teeth sensitivity.
Are you aware of grinding or clenching your teeth?
*
Yes
No
Please describe your grinding or clenching habits.
Are your jaws or teeth sore when you awake from sleep?
*
Yes
No
Please describe what soreness you feel after waking up.
Do you have headaches, earaches, or neck pains?
*
Yes
No
Please describe what type of pains you are experiencing.
Do you have any clicking, popping, or discomfort in the jaw?
*
Yes
No
Please describe what type of discomfort you have in the jaw.
Have you ever worn braces on your teeth?
*
Yes
No
Have you experienced any problems with anesthesia?
*
Yes
No
Please describe what problems you have had with anesthesia.
Please list all medications including OTC supplements you are taking:
*
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Medical History
Do you have any current health issues?
*
Yes
No
Health Issues
Date of Last Physical Examination
/
Month
/
Day
Year
Date
Physician Name
Physician Phone Number
Please enter a valid phone number.
Have you had a serious illness, operation, or been hospitalized in the past 5 years?
*
Yes
No
Describe the illness/problem
Have you ever had surgery, radiation therapy, or chemotherapy for tumors or other conditions?
*
Yes
No
Please describe your treatment (dates, dosages, surgeries, etc.)
Do you have any allergies that you are aware of?
*
Yes
No
Please specify what type of allergies you have
Have you had an adverse reaction to antibiotics, metals, jewelry, or other medications?
*
Yes
No
Please specify type of reaction
Have you taken, are you taking, or are you scheduled to begin taking: oral bisphosphonates - (Alendronate (Fosamax), Ibandronate (Boniva), OR Risedronate (Actonel) OR Intravenous Bisphosphonate: Pamidronate (Aredia) or Zoledronic Acid (Zometa)
*
Yes
No
What Drug, Dose, Frequency, and Duration?
Do you have or have you had any of the following diseases, problems, or symptoms?
*
Yes
No
Cardiovascular/Heart Problem
Neurologic Problem
Abnormal Bleeding or Clotting
Blood/Hematologic Disorder
Kidney/Liver Disorder
Immunosuppression
Asthma
Sleep Apnea
Respiratory Problem
Do you have or have you had any form of diabetes?
*
Yes
No
Please list your most recent A1C:
Please explain what disease(s), problem(s), or symptom(s) you have
Have you tested positive for HIV/AIDS, Hepatitis or any other infectious disease?
*
Yes
No
Describe the infectious disease
Any conditions or infections we should be aware of?
*
Yes
No
Describe the conditions/infections you have
Do you currently or have you ever used tobacco products?
*
Yes
No
Describe the type of tobacco, amount, and duration of usage
Do you currently or have you ever used illegal or illicit drugs?
*
Yes
No
Describe the type, amount, and duration of usage of the illegal drugs
Are you pregnant?
*
Yes
No
How many weeks are you?
Are you nursing?
*
Yes
No
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CHILDREN ONLY
Is this the Child's first visit to the dentist?
*
Yes
No
Does the child suck the thumb, fingers, or pacifier?
*
Yes
No
What does the child stick/suck in their mouth?
Is the child extremely nervous about dentistry?
*
Yes
No
Has the child had any difficult visits to the physician or hospital?
*
Yes
No
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CERTIFICATION AND SUBMISSION
I certify that the information provided above is current and correct to the best of my knowledge.
*
I agree
Signature
*
Clear
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: