Welcome

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as
completely as you can. We look forward to working with you in maintaining your dental health.
Name __________________________________________________________________
Soc Sec. # ______________________________________
Address ________________________________________________________________
City ___________________________________ State _______ Zip _________________
Home Phone _____________________________ Cell Phone ______________________
Email __________________________________________________________________
Sex M F birthdate ______________________ Single Married
Patient employed by ____________________________ Occupation ________________
Notify in case of emergency ____________________________ Phone ______________
Insurance
Subscribers Name ____________________________ Relationship to patient _________
Birthdate ______________ SS/ID # _________________ Insurance company _________
Group # _____________________ Insurance phone # ___________________________
(If available, please bring your insurance card to your appointment)
Secondary Subscribers name _____________________ Relationship to patient _______
Address & Phone (if different from patient) ____________________________________
Birthdate ___________ SS/ID # _________________ 2nd Insurance company _________
Group # _____________________ Insurance phone # ___________________________
Dental History
Former dentist ______________________ Date of last dental care __________________
Circle if you have had problems with any of the following:
Bad breath
Food collection between teeth
Bleeding gums Grinding or clenching of teeth
Sensitive to hot Sensitive when biting

Deep cleaning
Sensitive to sweets
Dry mouth
Sensitive to cold
Loose teeth or broken fillings
Clicking or popping jaw Sores or growths in mouth

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?
Yes No

Medical History
Physicians Name ___________________________ Phone ______________________________
Have you had any serious illnesses or operations? Yes No

If yes, give dates & describe

______________________________________________________________________________
Are you currently under physician care? Yes No If yes, describe ________________________
Have you ever had a blood transfusion? Yes No If yes, approximate dates ________________
Have you ever taken Fen-Phen/Redux? Yes No
Women:
Are you pregnant? Yes No

Nursing? Yes No

Taking birth control pills? Yes No

Circle yes or no whether you have had any of the following:

Abnormal bleeding Yes
Allergies/Hay fever Yes
Anemia
Yes
Angina
Yes
Arthritis
Yes
Artificial Joints
Yes
Asthma
Yes
Atopic
Yes
Blood disease
Yes
Cancer
Yes
Chest Pains
Yes
Diabetes
Yes
Dizziness
Yes
Emphysema
Yes
Excessive bleeding Yes
Fainting/seizures
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Glaucoma
Yes No
Hay fevers/Allgs Yes No
Head injuries
Yes No
Headaches
Yes No
Heart Murmur Yes No
Pre-med needed?
Heart problems Yes No
describe __________
Hepatitis
Yes No
High Blood Prs Yes No
HIV/AIDS
Yes No
Iodine Allergy Yes No
Jaundice
Yes No
Jnt replment/impt Yes No
Pre-med needed?
Kidney Disease Yes No

Latex Allergy
Yes No
Leukemia
Yes No
Liver disease
Yes No
Nervous Problems
Yes No
Psychiatric Care
Yes No
Pre-med needed
Yes No
Radiation trtmnt
Yes No
Respiratory Problem Yes No
Rheumatic Fever
Yes No
Rheumatism
Yes No
Sexual Trans Disease Yes No
Shingles
Yes No
Sinus Problems
Yes No
Stomach Prob/Ulcers Yes No
Thyroid problem
Yes No
Tuberculosis
Yes No

Is Patient currently taking any medications? If yes, list all:

Does patient have drug allergies? If yes, list all:

______________________________________________

___________________________________________

______________________________________________

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Authorization

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