3.- Dental Form

Dental Patient Form

Please fill out and submit this secure form to be scheduled for dental treatment. Items with a red * are required. There is no obligation in filling out this form.
Passport number is required. If you have applied but not received your passport, put "pending."
Time Frame For Treatment*
Patient Name*

TitleFirst NameMiddle NameLast Name
Preferred Name
Patient Gender
Spouses Name
Birth date*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Patient Birth Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Patient E-Mail*
Employer*
Occupation
Are you a full-time student at a college?

YesNo
If yes, name of college
Marital Status:

SingleMarriedDivorcedWidowedSeparatedDomestic Partner
Name of referring dentist in the USA, if any
How did you hear about our office?
Please check your preferred method of contact for appointment confirmation:*

E-MAILCELL PHONEHOME PHONE
Insurance - Primary
Subscriber Name
Relationship to Patient
Subscriber DOB
Subscriber SSN/ID
Subscriber Employer
Insurance Company Name
Insurance Company Address
Insurance Company Phone

Area CodePhone Number
Group Number
Insurance - Secondary
Subscriber Name
Relationship to Patient
Subscriber DOB
Subscriber SSN/ID
Subscriber Employer
Insurance Company Name
Insurance Company Address
Insurance Company Phone

Area CodePhone Number
Group Number
Medical History
Do you have a personal physician?

YesNo
Physician's Name
Physician's Phone

Area CodePhone Number
Date of Last Visit
Are you currently under the care of a physician?

YesNo
If yes, please explain
Do you use tobacco in any form?

YesNo
If yes, please list type and frequency of use
Do you have any artificial joints or implants?

YesNo
If yes, please list along with date of surgery
Are you taking any medication? If yes, please list each one
Do you have any allergies?

YesNo
If yes, please list

Do you have any of these conditions?*

	Yes	No
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Arthritis
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer
Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Facial Surgery
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
HIV + AIDS
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Joint Replacement
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Psychiatric Care
Radiation Therapy
Rheumatic Fever
Seizures
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers

If you are pregnant, how many weeks?
Do you have any disease, condition or problem that you feel we should know about? If so, please describe
Dental History
How may we help you today?*
Your current dental health is*

GoodFairPoor

Please answer the following*

	Yes	No
Do you require antibiotics before dental treatment?
Are you currently in pain?
Do you now or have you had any pain/discomfort in your jaw joint?
Are you aware of clenching or grinding your teeth?
Does it hurt when you chew or open wide to take a bite?
Do you have any jaw symptoms or headaches upon waking up in the morning?
Do you have pain in the face, cheeks, jaw, joints, throat or temples?
Do you like your smile?
Is there anything you would like to change about your smile?
Are you happy with the color of your teeth?
Have you ever had gum disease?
Do your gums bleed?
Have you ever had a deep cleaning or scaling and root planing?

How many times do you:
floss/week
brush/day

Please answer the following*

	Yes	No
Are your teeth sensitive to heat, cold or anything else?
Do you take fluoride supplements?
Have you ever had a serious/difficult problem with any previous dental work?
Have you ever had any unfavorable dental experiences?
Are you apprehensive about dental treatment?
Do you gag easily?

When was your last dental cleaning?
When was you last dental visit?
How can we accommodate you better during your dental visit?
Please tell us about dental work that you are considering at this time.*
You may upload any files here

Upload a File

Cancelof
Upload a File

Cancelof
Emergency contacts, relationships to you, and best ways to contact them.
Should be Empty:

Dental Patient Form

Insurance - Primary

Insurance - Secondary

Medical History

Dental History