About You
Today's Date: / /
Patient Name: Last: First: MI:
What You Prefer To Be Called: Male Female
Birthdate: / / Age: SS#:
Mailing Address:
City: State: ZIP:
Home Phone #: ( )
Work Phone #: ( ) Ext.:
Cell Phone #: ( )
E-mail Address:
Referred By:
Employer: How Long?
Employer's Address:
City: State: ZIP:
Status: Minor   Single   Married   Divorced Separated Widowed
Spouse's Name:
Do you have children? Yes No How Many?

Insurance Info
Primary Dental Insurance
Company Name:
City: State: ZIP:
Phone #: ( )
Insured's ID #:
Group # (Plan, Local, or Policy #):
Insured's Name:
Relation: Date of Birth: / /
Insured's Employer:
Secondary Dental Insurance
Company Name:
City: State: ZIP:
Phone #: ( )
Insured's ID #:
Group # (Plan, Local, or Policy #):
Insured's Name:
Relation: Date of Birth: / /
Insured's Employer:

Account Info
Person ultimately responsible for account
Billing Address:
City: State: ZIP:
Drivers License #:
Work Phone #: ( )
Payment Method: Cash Check
Credit Card #: Exp.: /
Initials: I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office).

In Event of Emergency
Whom should we contact?
Home Phone #: ( )
Work Phone #: ( )
Cell Phone #: ( )
Who is your Medical Doctor?
Medical Doctor's Phone #: ( )

Dental Information
Reason for today's visit: Exam Emergency Consulation
Are you in pain? No Yes How Long?
Please indicate any of the following problems:
Discomfort, clicking or popping in jaw Ringing in Ears
Red, swollen or bleeding gums Broken/Chipped tooth
Sensitive tooth, teeth or gums Stained teeth
Blisters/Sores in or around the mouth Locking Jaw
Lost/Broken Filling(s) Bad breath
Teeth grinding  
Do you require pre-medication? Yes No Don't know
Previous Dentist Name:
Phone: ( )
Last Dental exam: / /
Last Dental X-rays: / /
Times a day you brush?
Times a week you floss?
What type of tooth brush bristles do you use? Soft Medium Hard
How would you rate your smile?
(Worst) 1


Medical History

What medications are you taking? Nerve pills Pain killers (including aspirin) Muscle relaxers Stimulants Blood Thinnners Tranquilizers Insulin Meds for Osteoporosis
Other(s), please list:

Have you ever taken: Bisphosphonates (ex. Aredia/Fosamax) Yes No Phen-fen/Redux Yes No
Do you have or have you had any of the following diseases, medical conditions or procedures?
Y  N —Heart Attack / Stroke Y  N —Cancer/Tumors
Y  N —Heart Surg./Pacemaker Y  N —Shingles
Y  N —Heart Murmur Y  N —Hepatitis
Y  N —Rhuematic Fever Y  N —HIV+/AIDS/ARC
Y  N —Mitral Valve Prolapse Y  N —Arthritis/Rheumatism
Y  N —Artificial Valves Y  N —Artificial bones/Joints
Y  N —Heart Disease Y  N —Emphysema
Y  N —Congenital Heart Defect Y  N —Fainting/Seizures/Epilepsy
Y  N —Chest Pains Y  N —Severe/Frequent Headaches
Y  N —Sacrlet Fever Y  N —Frequent Neck Pain
Y  N —Nervousness Y  N —Back Problems
Y  N —Thyroid Problems Y  N —Cosmetic Surgery
Y  N —Kidney Problems Y  N —Xray or Cobalt Treatment
Y  N —Liver Problems Y  N —Chemotherapy
Y  N —Respiratory Problems Y  N —Asthma
Y  N —Sinus Problems Y  N —Difficulty Breathing
Y  N —Stomach Problems/Ulcers Y  N —Diabetes/Hypoglycemia
Y  N —Psychiatric Problems Y  N —Leukemia
Y  N —Venereal Disease Y  N —Anemia
Y  N —Alcohol/Drug Abuse Y  N —High/Low Blood Pressure
Y  N —Tuberculosis TB Y  N —Bleeding Problems
Y  N —Jaw Problems TMJ/TMD Y  N —Glaucoma
Please list any other surgeries or medical conditions you have or ever had:
Are you allergic to any of the following: Latex Penicillin/Amoxicillin Tetracycline Aspirin Dental Anesthetics Foods: Others:
Do you use tobacco No Yes How used? How much? How long?
Please rate your general health from 1-10: Do you wear contact lenses? Yes No
For women: Are you taking Birth Control pills? Yes No How many children have you had?
Are you Pregnant? No YesHow long? Are you nursing? Yes No


  • We invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between provider and patient.
  • Our policy rquires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.
  • I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authroize the provider to release any information required to process insurance claims.
  • I understand the above information and guarntee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
Initials: I acknowledge that I have recieved a copy of the Summary of Privacy Notice.

Signature: Date: / /
Adult Patient Parent or Guardian Spouse