Adult Patient Form

Fill out the form below to submit it online to our secure website. You can also download a copy of the form to fill and out bring with you to your appointment with the doctor.

  Download Form

* REQUIRED FIELDS

Name:  Last * First * MI
I prefer to be called: 
Birthdate:  / / Female Male
SS#:  DL#: 
Home Address: Street 
City:   Zip:
Single Married Other
Hm#: (
WK#: (  Ext: 
Cell#: ( )    Email:  *
Employer: 
Employer's Address: 
How long there?  Occupation: 
Where & when are the best times for appointments?
MTWTHF  Time:  AM PM
Other family members seen by us: 
Previous/Present Dentist: 
Phone#: ( )    Last Visit Date: 
Whom may we thank for referring you?

His/Her Name: 
Employer:   
Wk#: ( )   Ext: 
DOB:  / /
Neighbor or Relative not living with you.
His/Her Name:  Relationship: 
Wk#: ( )    Hm#: ( )  
Address: 
City: State :
Zip:


The benefits of a happy, healthly smile are immeasurable!
Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

Insurance Co Name: 
Address: 
Insurance Co. Phone#: ( )  
Group #: (Plan, Local or Policy#) 
Insured's Name:   Relation: 
Insured's Birthdate#:  / /   
Insured's SS#: 
Insured's Employer: 
Insured's Address: 

Insurance Co Name: 
Address: 
Insurance Co. Phone#: ( )  
Group #: (Plan, Local or Policy#) 
Insured's Name:   Relation: 
Insured's Birthdate#:  / /   
Insured's SS#: 
Insured's Employer: 

Name: 
Wk#: ( )   Ext:  Hm#:
Mailing Address#: 
Relationship: 
Employer:   
SS#:   DL#:

FINANCIAL
Payment is due in full at the time of treatment
unless prior arrangements have been approved.

If the office accepts my insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

 
 
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Signature                                                                        Date

 

 

Your current physical health is:  Good Fair Poor
Are you currently under the care of a physician?:  Yes No
Please explain: 
Do you smoke or use tobacco in any other form?  YesNo
Are you taking any prescription drugs?  Yes No
Please list: 
Have you ever take Phen-Fen or Redux?  Yes No
For Women: Are you taking birth control pills?  Yes No
Are you pregnant?  Yes No        Weeks#: 
Are you nursing?  Yes No
Have you ever had any of the following diseases or medical problems?
YN Abnormal Bleeding   YN Heart Surgery
YN Alcohol/Drug Abuse   YN Hepatitis
YN Anemia   YN Herpes/Fever Blisters
YN Heart Murmur   YN High Blood Pressure
YN Artificial Bones/Joints/Valves   YN HIV+/AIDS
YN Asthma   YN Kidney Problems
YN Blood Transfusion   YN Liver Disease
YN Cancer/Chemotherapy   YN Low Blood Pressure
YN Colitis   YN Mitral Valve Prolapse
YN Congenital Heart Defect   YN Pacemaker
YN Diabetes   YN Psychiatric Problems
YNDifficulty Breathing   YN Radiation Treatment
YN Emphysema   YN Rheumatic/Scarlet Fever
YN Epilepsy   YN Seizures
YN Fainting Spells   YN Sinus Problems
YN Arthritis   YN Thyroid Problems
YN Glaucoma   YN Tuberculosis
YN Heart Attack   YN Ulcers
       
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
YN Aspirin   YN Erythromycin
YN Codeine   YN Latex
YN Dental Anesthetics   YN Penicillin
YN Other  
Please list any other drugs that you are allergic to:
Do you have a personal physician?  Yes No
Physician's Name: 
Address: 
Phone#: ( )    Date of last visit: 
 

I verbally reviewed the medical/dental information above with the patient named herein.
Initials#:      Date:   
Doctors notes : 
 
What is your primary dental concern(s) ?
Are you in pain?  Yes No
Do you have any fear of dental work?  Yes No
Date of last dental exam: 
Have you ever had a serious/difficult problem
associated with any previous dental work?  Yes No
Have you had gum surgery/deep cleanings?  Yes No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ)? Yes No
Your current dental health is: Good Fair Poor
Do your gums ever bleed? Yes No
How many times a week do you floss?
How many times a day do you brush?
Do you snore? Yes No
Has anyone observed you stop breathing while asleep?
Yes  No
Do you like your smile? Yes No
If no, please explain:
Would you like fresher breath? Yes No
Whiter teeth? Yes No

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the Dental Office of any changes in my medical status. I also authorize the dental staff to perform the necessary dental services I may need, with my prior consent.

I also authorize the Dental Office to release any information, including the diagnosis and records of treatment or examination during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf. In the event of payment default for services previously rendered, I also agree to pay all reasonable collection and/or legal fees incurred in an attempt to collect on this amount.


__________________________________
Signature of Patient


Date:____/____/______