New Patient Form
Thank you for selecting Monadnock Perio and Implant Center for your dental healthcare! We promise that your experiences here will be comfortable, relaxed, and enjoyable in all ways to the best of our ability.
Patient Information
Name
*
First Name
Middle Name
Last Name
Gender
*
Please Select
Male
Female
By what name do you prefer us to call you?
*
Address
*
Street Address
Mailing Address (if different)
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Mailing Address (if different)
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
E-mail address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number (insurance purposes only)
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Separated
Student
Name of Employer
What Music makes you feel good?
Preferred Pharmacy
Emergency Contact Name
Day Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Whom may we thank for referring you to our practice?
Dental Benefits Information
(please bring your dental and medical card to your appointment if you have a card)
Policy Holder
Relationship
Date of Birth
-
Month
-
Day
Year
Date
SSN
Is this person currently a patient in this office?
Yes
No
Name of Employer
Insurance Company
Group ID #
Subscriber ID #
Insurance Company Address
Phone Number
Please enter a valid phone number.
Do you have secondary dental benefits?
*
Yes
No
Policy Holder
Relationship
Date of Birth
-
Month
-
Day
Year
Date
SSN
Is this person currently a patient in this office?
Yes
No
Name of Employer
Insurance Company
Group ID #
Subscriber ID #
Insurance Company Address
Phone Number
Please enter a valid phone number.
I consent to an examination by a dental provider. I understand that if treatment is recommended, I will have opportunities to ask questions before accepting or refusing treatment.
I authorize the dentist to release any information, including the diagnosis and the records of any treatment or examination provided to my child or me during the period of such dental care, to third-party payors and/or health practitioners.
I allow a photocopy of my signature to be used to process my insurance claims and will remain in effect until revoked by me in writing.
I authorize and request my insurance company to pay directly to the dentist any dental benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services, and I am responsible for any balances on my account.
A photocopy of this assignment is to be considered as valid as the original.
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Back
Next
Medical History
Name of PCP/Specialist
PCP/Specialist Phone #
Please enter a valid phone number.
Most recent visit
1. Are you under a physician’s care now?
*
Yes
No
2. Have you ever been hospitalized or had a major operation?
*
Yes
No
3. Have you ever had a serious head or neck injury
*
Yes
No
4. Do you take currently medications?
*
Yes
No
Please list medications, supplements, or non-prescription medications that you are currently taking
*
5. Do you have an artificial joint?
*
Yes
No
Pre-Medication Needed
*
Yes
No
6. Do you smoke or chew tobacco products?
*
Yes
No
7. Pregnant or trying to conceive
*
Yes
No
Are you allergic to any of the following?
1. Aspirin
*
Yes
No
2. Antibiotics - Penicillin, Amoxicillin, Clindamycin, Z-Pack
*
Yes
No
Other
Please list
*
3. Codeine/Oxycodone
*
Yes
No
4. Motrin/Ibuprofen
*
Yes
No
5. Local Anesthetics
*
Yes
No
6. Sulfa Drugs
*
Yes
No
7. Food
*
Yes
No
8. Latex
*
Yes
No
9. Other medications
*
Yes
No
Allergies
Aids/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Artificial Heart Valve
Artificial Joint(s)
Arthritis/Gout
Asthma
Auto Immune Disease
Bacterial Endocarditis
Bleeding Problems
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Circulatory Problems
Cold Sores/Fever Blisters
Congestive Heart Failure
Convulsions
Diabetes
Epilepsy or Seizures
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Gastric Reflux
Heart Attack
Hay Fever
Heart Disease
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Recent Heart Stent
Hemophilia
Hepatitis Type A
Hepatitis B or C
Herpes
High Cholesterol
High or Low Blood Pressure
Hives / Skin Rash
Irregular Heartbeat
Kidney Problems
Liver Disease
Organ Transplant
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Radiation Treatments
Renal Dialysis
Respiratory Disease
Rheumatoid Arthritis
Rheumatic Heart Disease
Rheumatic Fever
Scarlet Fever
Sexually transmitted disease
Sickle Cell Disease
Sinus Problems
Sleep Apnea/Snoring
Stomach / Intestinal Disease
Stroke
Thyroid Disease
Tonsillitis
Tumors or Growths
Mitral Valve Prolapse
Dental History
Dentist
Phone
Please enter a valid phone number.
Most recent visit
How often do you Brush?
Floss?
Other?
1. Are you having any discomfort/pain?
*
Yes
No
2. Are your teeth sensitive to hot/cold?
*
Yes
No
3. Are your teeth sensitive to biting/chewing?
*
Yes
No
4. Do your gums bleed?
*
Yes
No
5. Do you clench/Grind?
*
Yes
No
6. Do you have pain in jaw or in front of ear?
*
Yes
No
7. Do you have a bad taste or odor?
*
Yes
No
8. Do you breathe through your mouth?
*
Yes
No
9. Are you nervous about dental treatment?
*
Yes
No
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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