Address
City State Zip
Home Phone Cell Phone
Email* Sex MF Age DOB
SingleMarriedWidowedSeparatedDivorced
Employed by Occupation
Business Address
Business Phone Business Email
May we call you at work? YN
Notify in case of emergency
Home Phone Cell Phone
Business Phone Email

Whom may we thank for referring you?

Person Responsible for Account

Relation to Patient DOB Soc Sec #
Address (if different from patient)
City State Zip
Home Phone Cell Phone
Email
Employed by Occupation
Business Address
Business Phone Email
Insurance Company Phone
Insurance Email Contract #
Group # Subscriber ID

Is patient covered by additional insurance? YN

Subscriber Name
Relation to Patient DOB Soc Sec #
Address (if different from patient)
City State Zip
Home Phone Cell Phone
Email
Employed by Occupation
Business Address
Business Phone Email
Insurance Company Phone
Insurance Email Contract #
Group # Subscriber ID

Physician’s name Phone
Date of last visit Have you had any serious illnesses or operations? YN
If yes, please describe

Are you in good health? YN
Has there been any change in your general health in the past year? YN
Are you currently under physician care? YN
If yes, describe
Have you ever had a blood transfusion? YN
If yes, give approximate dates
Have you ever taken Fen-Phen/Redux? YN
Women: Are you pregnant? YN
Nursing YN
Taking Birth Control Pills? YN

Are you using any of the following?

Antibiotics? YN
Anticoagulants (blood thinners)? YN
Aspirin or drugs such as Motrin, Aleve, Ibuprofen? YN
High Blood Pressure medications? YN
Steroids (Cortisone, etc.)? YN
Weight loss medications (Fen-Phen)? YN
Tranquilizers and/or antidepressants? YN
Insulin or Oral Anti-Diabetic drugs? YN
Digitalis, Inderal, Nitroglycerin or other heart drug? YN
Recreational Drugs? YN
Are you taking or have you ever taken Bisphosphonates (such as Fosamax or Actonel for osteoporosis, or chemotherapy for multiple Myeloma, etc.)? YN

Please list any and all medications taken, including prescription and over-the-counter medications, herbal or holistic remedies, vitamins or minerals:

Indicate which of the following you have had or have at present:

Are you allergic to or have you had an adverse reaction to:

Local Anesthesia (Novocain, etc)? YN
Penicillin or other antibiotics? YN
Sedatives, Barbituates? YN
Aspirin or Ibuprofen? YN
Codeine or other pain killers? YN
Latext or Rubber Products? YN
Jewelry or Metals? YN

Other allergies or reactions? Please list:

Do you have a history of Alcohol or Chemical Dependency or Emotional Disorder? YN

Do you have any other disease, condition or problem not listed above that you think the doctor should know about? YN

What would you like us to do today?
Are you in dental discomfort today? YN
Former Dentist Address
Dentist’s Email Phone
Date of last dental care Date of last x-rays Date of last hygiene visit

Have had problems with any of the following:

How often do you brush?
How do you feel about the appearance of your teeth?
Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? YN
Other information about your dental health or previous treatment

Are you apprehensive about dental work? NoSlightModerateExtreme
Are you interested in Sedation Dentistry? YN
Are you interested in learning more about?
InvisalignTeeth WhiteningImplantsCerec One Visit DentistryBotox and Juvederm

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
With whom may we discuss your dental or financial situation? Please list name(s) and relationship.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to
inform this office of any changes in my medical status.
I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I
authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges
whether or not paid by insurance.