Confidential Patient Information
Personal Information:
Patient Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
-
Area Code
Phone Number
Patient Birth Date
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Year
Patient E-Mail
Gender
Please Select
Male
Female
Occupation
Spouses Name
Marital Status:
Single
Married
Divorced
Widowed
Separated
Domestic Partner
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Person Responsible for Account
Name
Relationship to Patient
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
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Dental Insurance Information
Primary Insurance Company
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee with Insurance
First Name
Last Name
Employer
Relationship to Patient
Policy Number
Group Number (if applicable)
Secondary Insurance Company
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee with Insurance
First Name
Last Name
Employer
Relationship to Patient
Policy Number
Group Number (if applicable)
I understand that payment is my obligation regardless of insurance or any other third party involvement.
For your convenience, we offer the following methods of payment. Please check the option you prefer:
Cash
Check
Credit Card
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Health Information
Personal Physician Name
Have you been hospitalized within the past 2 years?
Yes
No
If yes, for what?
Are you currently being treated by a physician?
Yes
No
If yes, for what?
Are you currently taking medications or drugs?
Yes
No
If yes, for what?
Have you ever received counseling for excessive use of alcohol and/or prescription drugs?
Yes
No
If yes, please specify:
Are you allergic to any medications?
Yes
No
If yes, which ones?
Place a mark on “yes” or “no” to the following:
Yes
No
Do you bleed excessively upon injury?
Are you pregnant?
Have you ever been involved with dental medical legal activity?
Are you allergic to latex?
Are you allergic to any metals?
Yes
No
Which ones?
Have, you ever had a skin rash or other reaction to metal jewelry?
Yes
No
Please specify to what?
Place a mark on “yes” or “no” to indicate if you have had any of the following:
Yes
No
A. AIDS
B. Arthritis
C. Asthma
D. Cancer
E. Diabetes
F. Epilepsy
G. Glaucoma
H. Heart Murmur
I. Heart Problem
J. Hepatitis
K. High Blood Pressure
L. Jaundice
M. Kidney Problems
N. Low Blood Pressure
0. Nervous Breakdown or Psychiatric Therapy
P. Rheumatic Fever
Q. Stroke
R. Sexually Transmitted diseases
S. Tuberculosis
T. Other Diseases
*If you checked "yes" for either I or T, please describe:
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Dental History
Former dentist
City / State
Reason for today’s visit
Date of last dental visit
Date of last dental X-rays
Date of last dental visit
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
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1
2
3
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5
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31
Day
Please select a year
2024
2023
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2021
2020
2019
2018
2017
2016
2015
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2013
2012
2011
2010
2009
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2003
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1999
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1982
1981
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1978
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1932
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1930
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1928
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1925
1924
1923
1922
1921
1920
Year
Date of last dental x-rays
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Place a mark on “yes” or “no” to indicate if you have had any of the following:
Yes
No
Bad breath
Bleeding gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growths in your mouth
How often do you floss?
How often do you brush?
Do you like your smile?
*
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For Office Use Only
Patient Name
Initial Update
Update / By:
Update / By:
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