Items marked with asterisk (*) must be completed.
PATIENT INFORMATION
First Name
*
Middle Name
Last Name
*
I prefer to be called (Nickname)
Address
Street
City
State/Province
Zip/Postal Code
Country
Home Phone
Work Phone
Cell/Other Phone
Gender:
Male
Female
Birth date (MM-DD-YYYY)
*
Social Security Number
Email Address
Social Security Number
If patient is a minor, give parent's or guardian's name
Other family members seen by us
Whom may we thank for referring you to our office?
RESPONSIBLE PARTY INFORMATION
Check here if this information is the same as "Patient Information". If so, proceed to employer information.
Full Name
Employer
Number of Years Employed
Birth date
Address
Street
City
State/Province
Zip Code
Country
How long at this address?
years
Work Phone
Cell/Other Phone
Social Security Number
Email Address
Relationship to Patient
Occupation
Responsible Party #2
Work Phone
Email Address
Mailing Address (if different)
Street
City
State/Province
Zip code
Country
Home Phone
Cell/Other Phone
Previous Address
Street
City
State/Province
Zip/Postal Code
Country
if less than 3 years
Birth date
Employer
Number of Years Employed
Relationship to Patient
Occupation
Social Security Number
Home Phone
Cell/Other Phone
DENTAL INSURANCE INFORMATION
Insured’s Name
Insured's Social Security Number (U.S. only)
Insurance Company
Group No.
Local Number (if applicable)
Insurance Company Phone Number
Insured's Name
Insurance Company
Local Number (if applicable)
Insurance Company Phone Number
Insurance Company Address
Street
City
State/Province
Zip/Postal Code
Country
Check here if you have dual coverage and complete the following information below.
Insured's Social Security Number (U.S. only)
Group Number
Insurance Company Address
Street
City
State/Province
Zip/Postal Code
Country
EMERGENCY INFORMATION
Name of nearest relative not living with you
Phone
Complete Address
Street
City
State/Province
Zip/Postal Code
Country
MEDICAL HISTORY
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Physician
Phone
Address
Street
City
State/Province
Zip/Postal Code
Country
Date of Last Visit
Please check any of the following which apply to you, and add any relevant comments.
Are you taking any medication?
Please list.
Are you allergic to any medication?
Please list:
Are you allergic to latex products?
Do you have a history of any major illness?
Have you had any major operations?
Please describe:
Have you ever been involved in a serious accident?
Please describe:
Have you seen a physician in the last 12 months?
Please explain:
For what reason?
Please check any of the following that you have had or currently have:
Abnormal bleeding/Hemophilia
Anemia
Arthritis
Asthma or Hay fever
Bone Disorders
Congenital Heart Defect
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
Herpes
High Blood Pressure
HIV/Aids
Kidney Problems
Pneumonia
Nervous Disorders
Prolonged Bleeding
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor or Cancer
Are there any medical conditions or other information we have not discussed that you feel we should be aware of?
Please discuss:
DENTAL HISTORY
General Dentist
Phone
What concerns you most about your teeth?
Address
Street
City
State/Province
Zip/Postal Code
Country
Date of Last Dental Visit
What would you like to change about your smile?
Please check any of the following which apply to you, and add any relevant comments.
Are you presently in any dental pain?
Comment:
Have you ever experienced any unfavorable reaction to dentistry?
Comment:
Have you ever lost or chipped any teeth?
Comment:
Have there been any injuries to face, mouth or teeth?
Comment:
Is any part of your mouth sensitive to temperature?
Comment:
Is any part of your mouth sensitive to pressure?
Comment:
Do you have any type of thumb or tongue habit?
Comment:
Are you a mouth breather?
Comment:
Have you ever seen an orthodontist?
If yes, who?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
When?
Are you aware of your jaws clicking or popping?
Comment:
Are you aware of clenching your teeth during the day?
Comment:
Have you ever been told that you grind your teeth?
Comment:
Do you have 'tension' headaches?
Comment:
Have you ever experienced chronic ringing in your ears?
Comment:
Have you tonsils or adenoids been removed?
Comment:
Any speech problems or speech therapy?
Comment:
Female Patients only:
Are you pregnant?
Comment:
Has menstruation started?
Comment:
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Date:
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