www.dentalvirtue.com - New Patient Form (Adult)

Welcome

We are pleased to welcome you to Virtue Dental Care. Please take a few minutes to read and fill out this form completely. If you have any questions, we are glad to help you.
Patient information
Name *

First Name Middle Name Last Name
Preferred Name
Soc. Sec #
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email *
example@example.com
Cell Phone *

Area Code Phone Number
Sex *
Birth Date *

Month Day Year
Date
Marital Status
Patient employed by
Occupation
Whom may we thank for referring you
Notify in case of emergency *
Phone *

Area Code Phone Number
Primary Insurance
Person responsible for Account

First Name Middle Name Last Name
Relation to patient
Birth Date

Month Day Year
Date
Soc Sec #
Address (if different from patient)

Street Address

Street Address Line 2

City State

Zip Code
Home Phone

Area Code Phone Number
Responsible Person employed by
Insurance Company
Phone

Area Code Phone Number
Subscriber ID#
Group #
Dental History
What would you like to accomplish with your appointment? *
Are you experiencing dental discomfort today? *
Date of last dental visit

Month Day Year
Date
Reason for the last visit *
Date of last x-rays?

Month Day Year
Date
Select all that apply to you *

Bad Breath Food collects between teeth Periodontal treatment Bleeding gums Grinding or clenching Sensitivity Clicking/popping/pain of jaws Loose teeth or broken fillings Sores or growths None
How often do you brush your teeth? *
Floss? *
How do you feel about the appearance of your teeth/smile? *
Have you ever experienced an adverse reaction to dental anesthetic? *
Type of bristles on your toothbrush *

Hard Medium Soft
Medical History
Physician’s Name

First Name Last Name
Phone

Area Code Phone Number
Date of last visit

Month Day Year
Date
Have you had any illnesses, operations, hospital stays? *

Yes No
If yes, please explain *
Are you currently under the care of a physician? *

Yes No
If yes, describe *
Women Only
Are you pregnant? *

Yes No
Nursing? *

Yes No
Taking birth control? *

Yes No
Select all that apply to you *

AIDS/HIV Positive Anaphylaxis Anemia Arthritis Asthma Allergies Back Problems Blood Disease Cancer Chemical dependency Chemotherapy Circulatory problems Cough (persistent) Cough (with blood) Developmental delays Dementia/Alzheimer's Diabetes Endocrine Abnormality Epilepsy/Seizure Eye disorders Fainting Food allergies Headaches Hearing problems Heart Murmur Heart Problems/Stent Hemophilia/bleeding Herpes Hepatitis High Blood Pressure Kidney problems Mitral Valve Prolapse Nervous problems Organ Transplant Pacemaker Psychiatric care Rapid weight gain or loss Respiratory disease/COPD Shingles Stroke Tobacco habit Tonsillitis Tuberculosis Liver disease None
Date/Organ
Do you take current medications? *

Yes No
Please list current medications/dose *
Are you allergic to any of the following *

Aspirin Penicillin Jewelry/metals Mercury Sulfa drugs Codeine Latex Nitrous oxide Casein (milk protein) Dental Anesthetic None Other
Do you have a medical condition that requires you to take antibiotics before dental treatment, such as *

Artificial Joint Artificial Heart Valve (or repair) History of Infective Endocarditis None
Have you had any of the following in the last 6 months *

Heart attack Stroke Stent Placement None
Have you ever taken Fosamax or any other bisphosphonate? *

Yes No
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 are any changes in my medical status, I 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 the services rendered. I authorize the use of the signature on all insurance submissions

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

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Payment Is due in full at the time of treatment, unless prior arrangements have been approved
Should be Empty:

Welcome

Patient information

Primary Insurance

Dental History

Medical History

Women Only

Authorization