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 *

Title First Name Middle Name Last Name
Preferred Name
Patient Gender
Spouses Name
Birth date *

Address *

Patient Birth Date *

Month Day Year
Home Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell Phone

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

Yes No
If yes, name of college
Marital Status:

Single Married Divorced Widowed Separated Domestic 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-MAIL CELL PHONE HOME 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 Code Phone 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 Code Phone Number
Group Number
Medical History
Do you have a personal physician?

Yes No
Physician's Name
Physician's Phone

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

Yes No
If yes, please explain
Do you use tobacco in any form?

Yes No
If yes, please list type and frequency of use
Do you have any artificial joints or implants?

Yes No
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?

Yes No
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 *

Good Fair Poor

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?

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?

Dental Patient Form