Thank you for selecting our dental healthcare team!
We will strive to provide you with the best possible dental care.
To help us meet all your dental healthcare needs, please fill out this form.
If you have any questions or need assistance, please ask us!
  • PATIENT INFORMATION
  • Date
  • Name:
  • Birthdate:
  • Home Phone:
  • Address:
  • City:
  • State:
  • Zip:
  • Sex:
  • MaleFemale
  • ChildSingleMarriedDivorcedWidowedSeparated
  • Email:
  • Cell Phone:
  • SSN:
  • If student name of School:
  • City:
  • State:
  • Full timePart Time
  • Employer:
  • Address:
  • Work Phone:
  • Spouse/Parent/Guardian's Name:
  • Number:
  • Spouse/Parent/Guardian's Employer:
  • Number:
  • Whom may we thank for referring you?
  • Person to contact in case of emergency:
  • Phone:
  • Relationship:
  • RESPONSIBLE PARTY
  • Name of Person
    Responsible for this account:
  • Relationship to Patient:
  • Address:
  • Home Phone:
  • Birthdate:
  • Employer:
  • Currently a patient in the office?
  • YesNo
  • INSURANCE INFORMATION
  • Name of Insured:
  • Relationship to Patient:
  • Birthdate:
  • Social Security #
  • Employer:
  • Phone Number:
  • Employer Address:
  • City:
  • State:
  • ZIP:
  • Insurance Company:
  • Group #:
  • Group Name:
  • Member ID:
  • Address:
  • City:
  • State:
  • ZIP:
  • ADDITIONAL INSURANCE
  • Name of Insured:
  • Relationship to Patient:
  • Birthdate:
  • Social Security #
  • Employer:
  • Phone Number:
  • Insurance Company:
  • Group #:
  • Group Name:
  • Member ID:
  • Address:
  • City:
  • State:
  • ZIP:

  • Medical History Although dental personnel primarily treat the area around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
  • Name:
  • Phone:
  • Date of last medical exam:
  • What was the exam for?
  • Current Physician:
    • Yes No
      Are you having pain or discomfort at this time?
      Do you feel very anxious about having dental treatment?
      Have you ever had a bad experience in a dental office?
      Have you ever been hospitalized or had a major operation?
      Are you under the care of a physician?
      Have you ever had a serious head or neck injury?
      Are you taking any medications, vitamins, or herbal supplements?
    • If yes, please list the medication, dose, & how often:
    • Do you take, or have you taken Phen-Fen or Redux?
      Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
      Are you on a special diet?
      Do you use Tobacco?
      Do you use controlled substances?
    • Women
    • Yes No
      Are you pregnant or trying to get pregnant?
      Are you taking contraceptives?
      Are you Nursing?
    • Are you allergic to any of the following?
    • Aspirin
    • Metal
    • Penicillin
    • Latex
    • Local Anesthetics
    • Sulfa Drugs
    • Acrylic
    • Other
    • :
    • Codeine
    • NONE
  • CHECKED ALL THAT APPLY:
  • FAMILY HISTORY UNKNOWN?
  • YesNo
    • Yes No
      Acid Reflux
      AIDS\HIV Positive
      Alzheimer's Disease
      Anaphylaxis
      Anemia
      Angina
      Arthritis\Gout
      Artificial Heart Valve
      Artificial Joint:
    • What Joint?    
    • When?    
    • Asthma
      Blood Disease
      Blood Transfusion
      Breathing Problem
      Bruise Easily
      Cancer
    • Type?    
    • Chemotherapy
    • When?    
    • Chest Pains
      Cold Sores\Fever Blisters
      Congenital Heart Disorder
      Convulsions
      Cortisone Medicine
      Diabetes
      Drug Addiction
      Dry Mouth
      Easily Winded
    • Yes No
      Emphysema
      Epilepsy\Seizures
      Excessive Bleeding
      Excessive Thirst
      Fainting Spells\Dizziness
      Frequent Cough
      Frequent Diarrhea
      Frequent Headaches
      Genital Herpes
      Glaucoma
      Hay Fever
      Heart Attack\Failure
      Heart Murmur
      Heart Pace Maker
      Heart Trouble\Disease
      Hemophilia
      Hepatitis A
      Hepatitis B or C
      Herpes
      High Blood Pressure
      High Cholesterol
      Hives or Rash
      Hypoglycemia
      Inflammatory Disease
    • Type?    
    • Irregular Heartbeat
      Kidney Problems
      Leukemia
      Liver Disease
    • Yes No
      Low Blood Pressure
      Lung Disease
      Mitral Val. Prolapse
      Osteoporosis
      Jaw Pain
      Parathyroid Disease
      Psychiatric Care
      Radiation Treatments
    • When?    
    • Recent Weight Loss
      Renal Dialysis
      Rheumatic Fever
      Scarlet Fever
      Shingles
      Sickle Cell Disease
      Sinus Trouble
      Sleep Apnea
      Do you wear a c-pap?
      Spina Bifida
      Stomach Disease
      Stroke
      Swelling of Limbs
      Thyroid Disease
      Tonsillitis
      Tuberculosis
      Tumors or Growths
      Ulcers
      Venereal Disease
      Yellow Jaundice
  • HAVE YOU EVER HAD ANY SERIOUS ILLNESS NOT LISTED ABOVE?
  • YesNo
  • If yes, please explain:
  • To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in the medical status.
  • Signature of Patient, Parent, or Guardian:
  • Date:
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