Patient Information Form

Patient Information

Date

Patient's Name*

Address*

Information*

Patient's Email*

If patient is a minor, give parent's or guardian's name

How did you hear about us?

Responsible Party Information

Name*

Residence*

Mailing Address*

How long at this address?

Contact Info

Previous Address (if less than 3 years)

Relationship to patient

Employer

Insurance Information

Insured's Name*

Insured's Employer

Address

Do you have dual coverage?

Insurance Information #2

Insured's Name*

Insured's Employer

Address

Do you have dual coverage?

Emergency Information

Name of nearest relative living with you

Relative's Address

Relative's Phone

Consent

Signature (Parent's signature if minor)*

Updates (date & initials)*

Medical Health

Name and address of physician

Have you been under a physician's care during the past 2 years?

Have you been treated in a hospital in the past 2 years?

Have you ever had surgery?

If female: Are you taking hormones or birth control?

Are you pregnant or nursing?

Have you ever had a blood test for hepatitis?

Were you vaccinated?

Have you ever had canker sores on your lips, tongue, gums, or body?

Are you now taking or have you taken any prescription drugs during the past year?

Are you taking any over the counter medications?

Are you taking any blood thinners?

Are you allergic to

Penicillin

Codeine

Local Anesthesia

Please list other allergies

Have you had or do you now have

Have you any disease, condition, or problem not previously listed?

Dental Health

When was your last dental visit?

Are you having any dental problems that require immediate attention?

Local Anesthesia

Do any of the following cause tooth discomfort?

Do you have any of the following problems?

Have you had periodontal treatment?

Have you had orthodontic treatment (braces)?

Have you had any missing teeth replaced?

If so, how

Are you comfortable with the replacement?

Are you pleased with the result?

Have you ever had an unpleasant dental experience?

Please add anything you feel is important