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New Patient Information Form

For your convenience we have met all privacy requirements on a SSL secure server. Please fill them out and submit securely online, prior to your visit, assured that your privacy is maintained. Please note that it is important to fill in all the fields before submitting. Thank you.

About you

Patient Name: *


Preffered Name :
Patient Is :
Policy Holder
Responsible Party
Social security #: *
Sex:
Male Female
Birth Date: *
Age:
Home Address:
Home phone: *
( ) - -
Cell phone:
( ) - -
Work phone:
( ) - - -
Pager :
( ) - -
Email address: *
I would like to receive correspondences via E-Mail.
Marital Status:
Single
Married
Divorced
Widowed
Driver’s license#:
Employment Status:
Full Time
Part Time
Retired
Student Status:
Full Time
Part Time
Medical ID:
Employer ID:
Carrier ID:
Pref. Dentist:
Pref. Pharmacy:
Pref. Hyg.:
Physician Name:
Cell/Pager #:
( ) - -
Emergency Contact:
Relationship:
Phone::
( ) - -

Responsible Party (if someone other than the patient)

Name:
Mailing Address:
Home phone:
( ) - -
Cell phone:
( ) - -
Work phone:
( ) - - -
Driver’s license#:
Social security #:
Date:
Responsible Party is also :
Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder

Primary insurance

Name of insured:
Relationship to insured:
Self
Spouse
Child
Other
Social security #:
Birth date:
Employer :
Address:
Rem. Benefits:
Rem. Deduct:
Insurance company:
Address:

Secondary insurance (if applicable)

Name of insured:
Relationship to insured:
Self
Spouse
Child
Other
Social security #:
Birth date:
Employer :
Address:
Rem. Benefits:
Rem. Deduct:
Insurance company:
Address:

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is-a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?
Yes No
If yes, please explain:
Have you ever been hospitalized or had a major operation?
Yes No
If yes, please explain:
Have you ever had a serious head or neck injury?
Yes No
If yes, please explain:
Are you taking any medications, pills, or drugs?
Yes No
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?
Yes No
Have you ever taken Fosamax, Bonica, Actonel or any other medicatins containing bisposphonates?
Yes No
Are you on a special diet?
Yes No
Do you use tobacco?
Yes No
Do you use controlled substances?
Yes No
Women : Are you Pregnant / Trying to get pregnant?
Yes No
Women : Are you Taking oral contraceptives?
Yes No
Women : Are you Nursing?
Yes No

Are you allergic to any of the following?

Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa drugs
Local Anesthetics
Other, Please List:

Do you have, or have you had, any of the following?

AIDS / HIV Positive Yes No
Alzheimer�s Disease Yes No
Anaphylaxis Yes No
Anemia Yes No
Angina Yes No
Arthritis / Gout Yes No
Artificial Heart valve Yes No
Artificial joint Yes No
Asthma Yes No
Blood transfusion Yes No
Breathing problem Yes No
Bruise easily Yes No
Heart trouble / Disease Yes No
Heart attack / Failure Yes No
Stomach / Intestinal disease Yes No
Fainting spells / Dizziness Yes No
Cold sores / Fever blisters Yes No
Congenital heart disorder Yes No
Recent weight loss Yes No
Renal dialysis Yes No
Rheumatic fever Yes No
Rheumatism Yes No
Scarlet fever Yes No
Shingles Yes No
Sickle cell disease Yes No
High choesterol Yes No
Hemophilia Yes No
Hepatitis A Yes No
Hepatitis B or C Yes No
Herpes Yes No
High blood pressure Yes No
Hives or rash Yes No
Hypoglycemia Yes No
Irregular heartbeat Yes No
Kidney problems Yes No
Leukemia Yes No
Liver disease Yes No
Low blood pressure Yes No
Cortisone medicine Yes No
Diabetes Yes No
Drug addiction Yes No
Easily winded Yes No
Emphysema Yes No
Epilepsy or seizures Yes No
Excessive thirst Yes No
Chest pains Yes No
Frequent cough Yes No
Frequent diarrhea Yes No
Frequent headaches Yes No
Genital herpes Yes No
Glaucoma Yes No
Hay fever Yes No
Cancer Yes No
Heart murmur Yes No
Heart pace maker Yes No
Convulsions Yes No
Excessive bleeding Yes No
Sinus trouble Yes No
Spina bifida Yes No
Chemotherapy Yes No
Stroke Yes No
Swelling of limbs Yes No
Thyroid disease Yes No
Lung disease Yes No
Mitral valve prolapse Yes No
Pain in jaw joints Yes No
Parathyroid disease Yes No
Psychiatric care Yes No
Radiation treatments Yes No
Blood disease Yes No
Tonsillitis Yes No
Tuberculosis Yes No
Tumors or growths Yes No
Ulcers Yes No
Venereal disease Yes No
Yellow jaundice Yes No
Have you ever had any serious illness not listed above?
Yes No
If yes, please explain:
Do you require premedication for a joint replacement or heart condition?
Yes No
Comments:
*
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 (or patient's) health. It is my responsibility to inform dental office of any changes in medical status.
*Signature
Date