W E L C 0 ME

W E L C 0 M E!

ALLENDALE FAMILY AND COSMETIC DENTISTRY 70 W ALLENDALE AVE SUITE ALLENDALE NJ 07401 201.825.9229
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.
PATIENT INFORMATION
Last Name
Initial
First Name
Soc. Sec. #
Address
City
Zip
State
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
SingleMarriedWidowedSeparatedDivorced
Email
example@example.com
Sex

MF
Age
Birthdate

MonthDayYear
Date
Patient Employed by
Occupation
Business Phone

Area CodePhone Number
Whom may we thank for referring you?
Notify in case of emergency
Home Phone

Area CodePhone Number
Email
example@example.com
PRIMARY INSURANCE
Person Responsible for Account
Last Name
First Name
Relation to Patient
Birthdate

MonthDayYear
Date
Soc. Sec. #
Address (if different from patient)
City
State
Zip
Cell Phone

Area CodePhone Number
Email
example@example.com
Person Responsible Employed by
Home Phone

Area CodePhone Number
Business Phone

Area CodePhone Number
Occupation
Phone

Area CodePhone Number
Contract #
Group #
Subscriber #
Name of other dependents under this plan
ADDITIONAL INSURANCE
Is patient covered by additional insurance?

YesNo
Relation to Patient
Birthdate

MonthDayYear
Date
Address (if different from patient)
Soc. Sec. #
City
State
Zip
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
Business Phone

Area CodePhone Number
Phone

Area CodePhone Number
Group #
Subscriber #
Name of other dependents under this plan
Check Yes ( the box ) if you have had any of the following:
What would you like us to do today?

Bad breathFood collection between teethPeriodontal treatmentSensitivity to sweetsAre you in dental discomfort today?Sensitivity to coldSensitivity when bitingGrinding or clenching teethSensitivity to hotBleeding gumsSores or growths in mouthClicking or popping jawOther
Dental history
What would you like us to do today?
Are you in dental discomfort today?
Former Dentist
Address
Dentist's Email
example@example.com
Phone

Area CodePhone Number
Date of last dental care

MonthDayYear
Date
Date of last x rays

MonthDayYear
Date
How often do you brush?
How often do you Floss?
How do you fell about the appearance of your teeth
Are you currently under physician care ?
If yes, give approximate dates

MonthDayYear
Date
Other information about your dental health or previous treatment

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?
Physician's name
Phone

Area CodePhone Number
Check Yes (the box ) if you have had any of the following:
Are you currently under physician care?

AIDS/HIV PositiveShortness of breathJaw painShinglesAnaphylaxisCough up bloodKidney disease or malfunctionHave you ever used a bisphosphonate medication? Brand names include Fosamax, Actonel, Atelvia, Didronel and Boniva.AnemiaDiabetesLiver diseaseSkin rashTaking birth control pills?Arthritis, RheumatismEpilepsySpina BifidaMaterial allergies (latex, wool, metal, chemicals)If yes, give approximate dates Have you ever had a blood transfusion?Artificial heart valvesFaintingStrokeCough, persistentHave you had any serious illnesses or operations?Food allergiesSurgical implantArtificial jointsAsthmaGlaucomaMitral valve prolapseHeadachesSwelling of feet or anklesAtopic (allergy prone)Nervous problemsPacemakerHeart murmurBack problemsThyroid disease or malfunctionHeart surgeryHeart problemsNursing?If yes, describeBlood diseaseDescribeCancerPsychiatric careTobacco habitChemical dependencyHemophiliaRapid weight gain or lossChemotherapyTuberculosisRadiation treatmentCirculatory problemsAbnormal bleedingHerpesCortisone treatmentsHepatitisRespiratory diseaseUlcer/ColitisMEDICAL HISTORYVenereal diseaseHigh blood pressureRheumatic/Scarlet feverHave you ever taken Fen-Phen/Redux?Women: Are you pregnant?Other
If yes to any of the questions please, describe
Is patient currently taking any medications? If yes, list all
Does patient have drug 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 any change in my medical status, will inform the dentist. I authorize the insurance company indicated on this form to pay to 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 payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Signature

Clear
Date

MonthDayYear
Date
Phone Number

Area CodePhone Number
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Payment is due in full at time of treatment, unless prior arrangements have been approved.
Should be Empty:

W E L C 0 M E!

PATIENT INFORMATION

PRIMARY INSURANCE

ADDITIONAL INSURANCE

AUTHORIZATION