Patient Information

Patient's Full Name:
Name you like to be called by:
Patient Address:
Social Security #:
Home Phone:
Marital Status (please select one): Single Married Divorced Seperated Widowed
Employer/School:
Employer/School Phone #:
Emergency Contact
Relationship: Phone
Contact's Address
Patient Email:
Names and Ages of Children:

Whom may we thank for referring you?

Person Responsible For Account

Full Name:
Relation to Patient:
Address:
Date of birth: Home Phone:
If less than three years at above address, previous address:

Marital Status (please select one): Single Married Divorced Seperated Widowed
Occupation:
Years at Employer: Driver's License #:
Social Security #:
Employer's Address:
Work Phone:
Name of spouse, other parent or secondary responsible person:
Full Address:
Date of birth: Home Phone:
Work Phone: Social:
Employer: Years at Employer:
Type of business:

Insurance Information

If you have insurance, this section must be completed.

Dental Insurance Company (name and address):

Name of Subscriber/Policy Holder:
Group #: Identification #:
Other Numbers:

Secondary Dental Insurance Company (name and address):

Name of Subscriber/Policy Holder:
Group #: Identification #:
Other Numbers:

Medical Insurance Company (name and address):

Name of Subscriber/Policy Holder:
Group #: Identification #:
Other Numbers:

Secondary Medical Insurance Company (name and address):

Name of Subscriber/Policy Holder:
Group #: Identification #:
Other Numbers:

Release

I authorize the doctor or other dentists or health-care professionals (interdisciplinary team members) to perform diagnostic procedures and treatment as may be necessary for proper dentofacial care.
I authorize release of any information concerning my (or my child's) health care for advice and treatment procided for the purpose of evaluation and administering claims for insurance benefits.
I authorize release of any information concerning my (or my child's) health care for advice and treatment to interdisciplinary team members.
I consent to the release of credit reports and information regarding my credit history to the doctor(s).
I authorize the taking of photographs, radiographs and other diagnostic records before, during and after treatment, and to the use of the same by the doctor or interdisiplinary team members in scientific presentations or scientific literature.

Enter today's date:
Check this circle to digitally sign this form.

Medical and Dental History

Patient's Full Name:
Date of birth: Age (years/months):
Male Female
Weight: Height:
Patient's current previous Dentist(s):
Patient's current previous Physician(s):
Date of last dental cleaning:
Date of last physical exam:

All past medical and dental history may be important for your optimal care. Please take time to be as accurate and thorough as possible in answering the following questions. Thank you.

A. Please list your chief concerns for treatment (in order of priority):

B. What or who motivated you to seek treatment and what do you expect?

C. Describe anything that bothers you about the appearance of your teeth, smile or face:

D. Describe any injuries or blows to your face, jaw, mouth or teeth:

E. List all current medications including non-prescriptions:

F. List all drug allergies:

G. List all previous surgeries or hospitalizations:


For the following section, please check the box next to each appropriate question, then use the box below to describe thoroughly (refer to the proper numbers).

1. High blood pressure
2. Chest pains or heart attack
3. Stroke
4. Rheumatic Fever
5. Shortness of breath or swollen ankles
6. Any heart trouble, murmer, or mitral valve prolapse
7. Prosthetic devices (heart, valve, hip, etc)
8. Any lung disease (TB, emphysema, etc)
9. Asthma
10. Allergies or hay fever
11. Sinus problems
12. Mouthbreathing or excessive snoring
13. Ulcers or stomach problems
14. Diabetes
15. Hepatitis or liver disease
16. Kidney or bladder disease
17. Thyroid trouble
18. Connective tissue disease
19. Sexually transmitted disease
20. Arthritis or rheumatism
21. Cancer (list type and dates)
22. Serious illness not listed (list types, dates)
23. Subject to prolonged bleeding or bruise easily
24. A contact lens user
25. Glaucoma
26. Epilepsy, convulsions or seizures
27. Psychiatric therapy or emotional problems
28. HIV/AIDS
29. Have you been exposed to HIV?
30. Have you been tested for HIV?
31. Pregnant or possibly pregnant
32. Taking birth control pills
33. Drink coffee (list cups per day)
34. Consume alcoholic beverages
36. Pain, popping, catching or locking in jaw joints
37. Clench or grind your teeth
38. Wake up with sore jaws
39. Frequent headaches (list how many times per week)
40. Dizziness, ringing or pain in ears
41. Tenderness or stiffness in the jaw, neck or back
42. History of TMJ (jaw joint) problems or therapy

Dental

50. Treatment for or told you have gum disease
51. Treated or consulted for orthodontic therapy
52. Had any oral surgery
53. Dental x-rays taken in the last year
54. Excessive fear of dental treatment
55. Brush your teeth (list how often)
56. Floss your teeth (list how often)
57. Bad breath or unpleasant tastes in your mouth
58. Bleeding gums
59. Sore teeth
60. Tooth sensitivity
61. Fever blisters or mouth ulcers
62. Suck your thumb, finger or lip (now or in the past)
63. Tongue thrusting habit
64. Gag easily
65. A high priority of keeping your natural teeth

In the space below please expand on your entries above, listing the number and your thorough explanation.


Please check below to sign that the above information is accurate and complete to the best of your knowledge:
Date:
Parents or guardian's name:
I agree the above information is accurate and complete

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