Patient Information Form

Patient Information

Name

D.O.B.

Date

Address

Phone Number

Email Address

Social Security

Emergency Contact Name

Phone

Denatl Insurance Information

Primary Dental Insurance Company Name

Name Of Subscriber

D.O.B.

Subscriber ID#

Group

Employer

Secondary Dental Insurance Company Name

Name Of Subscriber

D.O.B.

Subscriber ID#

Group

Employer

Responsible Party

Person responsible for this account

Address

Phone Number

Patient Dental History

Name of previous dentist

Phone Number

Date of Last Exam or Visit

My gums bleed while brushing or flossing.

Yes

No

My teeth are sensitive to hot or cold liquids/foods.

Yes

No

My teeth are sensitive to sweet or sour liquids/foods.

Yes

No

I experience pain in my teeth.

Yes

No

I have sores or lumps in or near my mouth.

Yes

No

I have head, neck or jaw injuries.

Yes

No

I experience the following:

Clicking:

Yes

No

Difficulty in chewing:

Yes

No

Pain-joint, ear, side of face:

Yes

No

Difficulty in opening or closing:

Yes

No

I have frequent headaches.

Yes

No

I clench or grind my teeth.

Yes

No

I bite my lips or cheeks frequently.

Yes

No

I have difficulty with extractions.

Yes

No

I have/had orthodontic treatment

Yes

No

I wear dentures and/or partials.

Yes

No

I like my smile.

Yes

No

Medical History

PCP Name

Phone#

1. Are you under medical treatment?

Yes

No

2. Have you been hospitalized for any reason within the last 5 years?

Yes

No

3. Have you taken the diet drug Fen-Phen or Redux?

Yes

No

4. Have you taken any bisphosphonates (Reclast, Prolia, Fosamax, Boniva, Actonel)

Yes

No

5. Do you use tobacco?

Yes

No

6. Do/have you use/d any controlled substances?

Yes

No

7. Do you wear contact lenses?

Yes

No

8. Do you have a persistent cough or throat clearing issue not related to a known illness?

Yes

No

9. Do You Premed/Antibiotics For Dental Appointments?

Yes

No

10. Epinephrine Sensitivity?

Yes

No

11: Women Only

Are you pregnant?

Yes

No

Nursing

Yes

No

Are you taking oral contraceptives?

Yes

No

Authorization and Release

Pertaining to the above Patient Information and Medical History

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize and request my insurance company to pay the dental office directly. I will be responsible for the balance not covered by the insurance company and/or any outstanding balance on my account for services rendered.

Signature Of Patient (Or Parent/guardian If A Minor)

Date