The Measure Of Perfection

New Patient Form

Indicates Required Field
Patient Information
Last Name: First Name: MI: Date: (mm/dd/yyyy) Gender
Male Female
Marital Status       Social Security#: Birth Date: (mm/dd/yyyy)
Married Single Child Divorced Widowed Other
Phone (Home): (Work): Ext: Cell Phone:
Preferred appointment time and/or day: Morning Afternoon Evening Any Time   M T W T
Patient's Address: City: State: Zip Code:
Patient's Email Address: If a Student:
Full-Time Part-Time  
Emergency Contact: Relationship to Emergency Contact: Emergency Contact Phone:
Health Information
Date of Last Dental Visit : Previous Dentist :
Reason for today's visit:
Have you ever had any of the following? Please check those that apply
Allergies
Med Allergies
Anemia
Angina
Arthritis
Artificial Heart
  Valve, Surgery
Artificial Joints
Asthma
Blood Disease
Blood Transfusion
Cancer
Chemotherapy
Cortisone Medicine
Codeine Allergy
Congenital Heart
Cosmetic Dentistry
Crohn's Disease
Coumadin
Diabetes
Dizziness
Drug Addiction
Emphysema
Epilepsy or Seizures
Excessive Bleeding
  (Bruise Easily, Hemophilia)
Fainting
Fever Blisters
Glaucoma
Hay Fever
Headaches
Head Injuries
Heart Disease
Heart Murmur
Hepatitis A B C
High Blood Pressure
HIV
Hives
Jaundice
Kidney Disease
Leukemia
Mental Disorders
Mitral Valve Prolapse
Migraines
Nervous Disorders
  (Anxiety, BiPolar)
Neck Pain
Other
 
Pacemaker
Pain in Jaw
Premed
Psychiatric Treatment
Pregnancy
  Due Date:
 
Radiation Treatment
Respiratory Problems
  (Emphysema)
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Thyroid Disease
Tuberculosis
Tumors
Ulcers
Venereal Disease
  (Syphilis, Gonorrhea, etc)
Medications:
 
 
 
 
Have you ever had any complications following dental treatment? Yes No
  If yes, please explain:
 
Have you been admitted to a hospital or needed emergency care during the past two years? Yes No
  If yes, please explain:
 
For what:
Are you now under the care of a physician? Yes No
  Name of Physician: Phone:
 
Have you ever or are you planning to have treatment for Osteoporosis or other bone disease? Yes No
Do you have any health problems that need further clarification? Yes No
  If yes, please explain:
 
Do you have any dental fears?
Are you dissatisfied with your teeth and their appearance?
Are you deeply concerned about the finances required to return your teeth to excellent dental health?
Do you get frustrated because you always have something to be treated or repaired when you visit a dentist?
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Signature of patient, parent or guardian: Date:
Referral Information
Whom may we thank for referring you to our practice? Another patient, friend Another patient, relative
  Dental Office Yellow Pages Newspaper School Work Other
Name of person or office referring you to our practice:
Guarantor's Information (Responsible Party) - Only required if patient is a minor.
Is patient a minor? Yes No
Please fill out this section only if the patient is a minor & only if the patient will be accompanied by a responsible party who is not the Policy Holder on the insurance. If the patient is under 18 years of age, they must be accompanied by a parent or legal guardian.
Guarantor's Name: Gender
Male Female
Marital Status     Social Security#: Birth Date: (mm/dd/yyyy)
Married Single Child Divorced Widowed
Phone (Home): (Work): Ext: Cell Phone :
Guarantor's Home Address: City: State: Zip Code:
Guarantor's Email Address: Is Guarantor a Patient?
Yes No  
Guarantor's Employer Name: Occupation:
Employer Address: City: State: Zip Code:
Insurance Information
Is patient insured? Yes No
Primary Insurance - Only required if patient is insured.
Policy Holder Last Name: First Name: MI:      
Is the insured a patient? Yes No
Policy Holder Birth Date: Social Security#:
Policy Holder Home Address: City: State: Zip Code:
Policy Holder Employer Name:
Employer's Address: City: State: Zip Code:
Employer's Phone#:
Patient's relationship to insured: Self Spouse Child Other
Insurance Plan Name:
Insurance Address: City: State: Zip Code:
Insurance Phone #: Insurance Group#: Insurance ID#:
Secondary Insurance
Policy Holder Last Name: First Name: MI:      
Is insured a patient? Yes No
Policy Holder Birth Date: Social Security#:
Policy Holder Home Address: City: State: Zip Code:
Policy Holder Employer Name:
Employer's Address: City: State: Zip Code:
Employer's Phone:
Patient's relationship to insured: Self Spouse Child Other
Insurance Plan Name:
Insurance Address: City: State: Zip Code:
Insurance Phone #: Insurance Group#: Insurance ID#:
Please bring your insurance card with you on the day of your appointment.
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