Electronic Patient Forms Step 1 of 3 33% Name First Middle Last Email Contact Preference Call Text Email Preferred Name Sex Male Female Birthday Age Social Security Number Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Marital Status Single Married Divorced Widowed Home Phone Cell Phone Work Phone Best place and time to contact you? Referred By Other family members seen by us Present / Previous Dentist Date of Last Dental Visit Person Responsible for Account Name First Last Work Phone Ext. Home Phone Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Relation to patient Date of Birth Spouse Section Name First Last Date of Birth Phone In the event of an emergency, is there someone who lives near you we should contact? Yes No His/Her Name Relationship to Patient Work Phone Home Phone Dental History Why have you come to the dentist today? Do you require antibiotics before dental treatment? Yes No Have you ever had a serious/difficult problem associated with any previous dental work? Yes No Are you currently in pain? Yes No I have a fear of / I have a concern about Experiencing Pain Needles Gagging Being Embarassed Losing my teeth/False Teeth To understand what is going on in my mouth, my preference is : To know all the details To be given the bottom line To read pamphlets To talk with a team member about solutions to my problems Do you now have or have you ever experienced pain/discomfort in your jaw? (TMJ/TMD) Yes No Your current dental health Good Fair Poor How many times a week do you floss? Do your gums ever bleed? Yes No Types of bristles Hard Medium Soft Are you happy with your smile? Yes No Primary Insurance Information Primary Insurance Company Name Primary Insurance Street Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Insurance Company Phone Primary Insurance Group Number Insured’s First Name Insured’s Last Name Relation to Patient Insured's Birthday Insured's Social Security Number Insured's Employer Patient's Birthday School Name if Attending: Do you have secondary Dental Insurance Yes No Secondary Insurance Information Secondary Insurance Company Name Secondary Insurance Company Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Secondary Insurance Group Number Secondary Insurance Insured Name Secondary Insured First Name Last Name Relation to Patient Insured's Birthday Insured's Social Security Number Employer Name Patient Medical History Patient Name First Last Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Last Visit Date of Medical History Email Home Phone Work Phone Birthday Social Security Number Marital Status Single Married Divorced Widowed Primary Dental Guarantor Home Phone Work Phone Secondary Dental Guarantor Home Phone Work Phone Physician Name Physician Phone Pharmacy Name Pharmacy Phone Medical Alerts Patient Gender Female Male Are you taking birth control pills? Yes No Are you pregnant? Yes No Are you nursing? Yes No Do you smoke or use tobacco? Yes No BP Heart Rate Height Weight Existing Medical Conditions Abnormal Bleeding Alcohol Abuse Allergies Anemia Angina Pectoris Arthritis Artificial Bones Artificial Heart Valve Asthma Blood Transfusion Cancer- Chemotherapy Colitis Congenital Heart Defect Cosmetic Surgery Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Fainting Spells Fever Blisters Frequent Headaches Glaucoma Hay Fever Heart Attack Heart Surgery Hemophilia Hepatitis A Hepatitis B High Blood Pressure HIV + AIDS Kidney Problems Liver Disease Low Blood Pressure Mitral Valve Prolapse Pace Maker Pneumocystitis Psychiatric Problems Radiation Therapy Rheumatic Fever Seizures Shingles Sickle Cell Disease Sinus problems Stroke Thyroid Problems Tuberculosis Ulcers Venereal Disease Yellow Jaundice Allergies Aspirin Codeine Dental Anesthetics Erythomycin Jewelry Latex Metals Penicillin Tetracycline Allergies – Other/not listed above Please list your medications Is there any disease, condition, or problem that you think this office should know about that is not covered above? Yes No If Yes, Please provide any information you feel is relavant. Policies Your Appointment is reserved and requires 48 hour notice of cancellation. We reserve the right to charge a fee of $50 for every 1/2 hour of missed appointment for this time You Agree that we may release information to the insurance carrier regarding your records. Payment is due when services are rendered. All past due accounts of more than 30 days are subject to a 1.5% monthly finance charge. MY SIGNATURE BELOW INDICATES THAT I HAVE READ THIS ENTIRE FORM. PROVIDED CORRECT INFORMATION, AGREE TO THE CONDITIONS LISTED ABOVE AND THAT I UNDERSTAND THAT FILING INSURANCE CLAIMS IS MY RESPONSIBILTY It will be signed at office visit. Patient's Signature (if minor, Parent/ Guardian must sign) Date I DR. Passes, Have Reviewed the Medical History Doctor's Signature Date
