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Patient Information

Patient's Name

Nickname / SS#

If Minor, Parent or Guardian Responsible:

SS#

Billing Address

City / State / Zip

How long at this address

Patient's Birthdate / Guardian's Birthdate

Occupation / Employer / No. Years Employed

Home / Work / Cell Phone

Spouse's Name

Occupation / Employer / No. Years Employed

Spouse's Birthdate / Work Phone

Primary

Policy Holder Name

Date of Birth

Relationship to Patient

Insurance Company

Group #

Secondary

Policy Holder Name

Date of Birth

Relationship to Patient

Insurance Company

Group #

Patient Medical History

Family Dentist's Name

Physician's Name

Whom were you referred by?

Date of last physical

Are you undergoing medical treatment at this time?

Yes No

Have you been hospitalized for a surgical operation or serious illness in the last 5 years?

Yes No

Are you currently taking steroids or have you taken steroids in the last 2 years?

Yes No

Please list all medications (including supplements) you are currently taking:

Do you pre-medicate for dental appointments?

Yes No

Drug, Latex, and any other Allergies?

Yes No

If you are a woman, are you pregnant?

Yes No

Are you nursing?

Yes No

What are we seeing you for today?

Have you had periodontal therapy before?

I hereby state that the information on this form is true and correct to the best of my knowledge and understand that where appropriate, Credit Bureau Reports may be obtained. I agree to allow Mountain West Periodontal Associates to contact my dentist, physician, and other health care professionals as required to permit proper treatment. I authorize Mountain West Periodontal Associates, P.C. to release information to my doctors and insurance carriers.

Signature of patient and / or person responsible for payment. (Parent if minor)

Click to Sign

Date:-------------

truForm by PBHS

Main Header

Patient Information

Patient Information

Dental Insurance

Primary

Secondary

Patient Medical History

Patient Medical History

Do you have any of the following medical conditions? (check all that apply)

Click to Sign

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Main Header

Patient Information

Patient Information

Dental Insurance

Primary

Secondary

Patient Medical History

Patient Medical History

Do you have any of the following medical conditions? (check all that apply)

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.