We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Thank you for your cooperation.

patient information

First
Middle
Last
MM-DD-YYYY
Will be kept confidential for our use only
Street
City
State
Zip
If Applicable
First
Last

responsible party / insurance information

Primary

Marital Status:

Will be confidential for our use only
Secondary

Marital Status:

Will be confidential for our use only
Kids Tooth Club

List names and date of birth for any children in your family that can be entered into our tooth club! They will receive a Tooth Club T-Shirt, can earn Neal Notes that can be redeemed for prizes, and they will receive invitations to our fun events!

Dental and Medical History

Is patient in good health?

ADD/ADHD

AIDS/ARC

Anemia

Angina

Arthritis

Asthma

Blood Disorder

Bone Disorder

Cancer

Cold Sores

Diabetes

Dizzy Spells

Epilepsy

Fainting

Fever Blisters

GI Disorder

Headaches (Severe/Frequent)

Herpes

Heart Murmur

Heart Condition

Kidney Problems

Liver Problems

Low Blood Pressure

Nervous Disorder

Pneumonia

Psychiatric Problems

Radiation

Rheumatic/ Scarlet Fever

Tuberculosis

Ulcers/Colitis

Venereal Disease


Lip biting

Tongue Thrusting

Nail biting

Pen/Pencil Biting

Speech Problems

Teeth Clenching

Teeth Grinding

Tongue/ Thumb/ Finger sucking

Chewing/ Eating/ Problems

Mouth Breather

Snoring

Potential Obstructive Sleep Apnea

Signature

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my/my child's medical status.

I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and I authorize payment of any insurance benefits.

Patient/ Parent/ Guardian Yearly Review

initial and date
initial and date
initial and date