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*

MonthDay 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

MonthDay 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

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

MonthDay Year
Date
Select all that apply to you*

Bad BreathFood collects between teethPeriodontal treatmentBleeding gumsGrinding or clenchingSensitivityClicking/popping/pain of jawsLoose teeth or broken fillingsSores or growthsNone
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*

HardMediumSoft
Medical History
Physician’s Name

First Name Last Name
Phone

Area Code Phone Number
Date of last visit

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

YesNo
If yes, please explain*
Are you currently under the care of a physician? *

YesNo
If yes, describe*
Women Only
Are you pregnant?*

YesNo
Nursing?*

YesNo
Taking birth control?*

YesNo
Select all that apply to you*

AIDS/HIV PositiveAnaphylaxisAnemiaArthritisAsthmaAllergiesBack ProblemsBlood DiseaseCancerChemical dependencyChemotherapyCirculatory problemsCough (persistent)Cough (with blood)Developmental delaysDementia/Alzheimer'sDiabetesEndocrine AbnormalityEpilepsy/SeizureEye disordersFaintingFood allergiesHeadachesHearing problemsHeart MurmurHeart Problems/StentHemophilia/bleedingHerpesHepatitisHigh Blood PressureKidney problemsMitral Valve ProlapseNervous problemsOrgan TransplantPacemakerPsychiatric careRapid weight gain or lossRespiratory disease/COPDShinglesStrokeTobacco habitTonsillitisTuberculosisLiver diseaseNone
Date/Organ
Do you take current medications?*

YesNo
Please list current medications/dose*
Are you allergic to any of the following*

AspirinPenicillinJewelry/metalsMercurySulfa drugsCodeineLatexNitrous oxideCasein (milk protein)Dental AnestheticNoneOther
Do you have a medical condition that requires you to take antibiotics before dental treatment, such as*

Artificial JointArtificial Heart Valve (or repair)History of Infective EndocarditisNone
Have you had any of the following in the last 6 months*

Heart attackStrokeStent PlacementNone
Have you ever taken Fosamax or any other bisphosphonate?*

YesNo
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*

MonthDay 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