monroefamilydds.com - New Patient Form

Dental History

Reason for Today's Visit

Date

Date of last dental care

Date

Former Dentist

Date of last dental X-rays

Date

Address

Check If you had problem with any of the following

How often do you floss?

How often do you brush?

Medical History

Physician's Name

Date of Last Visit

Date

Have you ever taken of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

YesNo

Have you had any serious illnesses or operations?

YesNo

If yes, describe

Have you ever had a blood transfusion?

YesNo

If yes, give approximate dates

(Women) Are you pregnant?

YesNo

Nursing?

YesNo

Taking birth control pills?

YesNo

Check if you have or have had any of the following

MEDICATIONS List medications you are currently taking:

ALLERGIES

Authorization

I certify that I, and/or my dependent(s), have insurance coverage with

Name of Insurance Company(ies)

and assign directly to Dr

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Date

Please print name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

New Patient Registration