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
YN	Difficulty 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:____/____/______