Patient Forms —

Patient Information

Email Address

Please tell us your preferred method of appointment reminders, check all that apply:
HomeWorkCellTextEmail

Person to Contact In case of Emergency

Emergency Contact Phone #

Employer

How did you hear about us?
MailerInternetFriendOther

How did you hear about us? (Specify)

Insurance Information

Regardless of insurance, patients are ultimately responsible for all charges accrued. Therefore, we will send claims to your insurance company for all treatment; however, we ask that the insurance company be authorized to pay us directly, and you pay your estimated portion at the time of service.

Medical History

Are you happy with your smile?
YesNo

If no, what would you change?

Have you been seriously ill in the last 5 years?
YesNo

If yes, please explain:

Are you allergic to any drugs or substances?
YesNo

If yes, which ones?

Are you taking any medications, pills, or drugs? (prescription or herbal)
YesNo

If yes, please list:

Have you ever had a bad reaction to a dental injection of local anesthetic?
YesNo

Females, are you pregnant or nursing?
YesNo

Do you, or have you smoked or used smokeless tobacco?
YesNo

If yes, please explain usage (i.e. how much per day/week):

Please check if you have had any of the following:
High Blood Pressure TuberculosisAnemiaLow Blood PressureLung DiseaseAsthmaHeart MurmurEmphysemaLatex AllergyHeart PacemakerLiver DiseaseBruise EasilyArtificial Heart ValveHepatitisProlonged BleedingStrokeAIDS / HIVEpilepsy / SeizuresRheumatic FeverKidney TroubleThyroid DiseaseBacterial Endocarditis CancerHypoglycemiaHeart trouble not listedChemotherapy / RadiationArthritis / GoutArtificial JointsDiabetesOsteoporosisPain in jaw jointFrequent HeadachesDrug/Alcohol Dependency

Have you had any medical condition or serious illness not checked above?
YesNo

If yes, please explain usage:

Who may we speak with over the phone or in person regarding your account (other than a spouse)?

By checking the box, you consent to your data being stored according to the guidelines set out in the Privacy Policy. This acceptance is required to submit this form.

Responsible Party Name

Signature (Please print name)

Date of Signature

By checking the box, you consent to your data being stored according to the guidelines set out in the Privacy Policy. This acceptance is required to submit this form.

Responsible Party Name

Signature (Please print name)

Date of Signature

By checking the box, you consent to your data being stored according to the guidelines set out in the Privacy Policy. This acceptance is required to submit this form.