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Patient Information

Prefix

Mr. Mrs. Ms. Dr.

Sex

Male Female

Name

Birth Date / Age / Soc. Sec. #

Mailing Address

Phone Number

E-mail

Have you ever been a patient of our practice?

Yes No

Referred By

Dentist Name

Medical Doctor Name

Preferred Pharmacy / Pharmacy Tel.

In case of emergency

Please contact

Tel. / Relation

Who will be responsible for your account?

Father Mother Self Spouse Other

Who will be responsible for your account

Responsible Party Name / S.S.#

Responsible Party Birth Date / Age

Responsible Party Tel.

Responsible Party Address

Primary Dental Insurance Company

Employer

Bus. Address

Bus. Tel / Plan

Ins. Co. Name / I.D.#

Address

Tel. / Group # / Group Name

Insured Party / Relation / Sex

M F

Birth Date / S.S. #

Address

Tel.

Dental Information

Reason for today’s visit

Last dental exam

Last dental x–rays

Last dental cleaning

This section is for women only

Is there a possibility of pregnancy?

Yes No

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Women note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

Are you taking any kind of medication, drug, pills?

Yes No

Please list any medications you are currently taking

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Medication #13

Medication #14

Medication #15

Medication #16

Medication #17

Medication #18

Medication #19

Medication #20

Please list any other medication or antibiotic you are allergic to:

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

I permit the office to communicate with me via text message on my cell phone.

Yes No