Click on Calendar, type the year 'YYYY' and pick the month & date.

Please fill out this form

Patient Information

*Patient Name:

First name

Last name

Date of Birth:

*Cell Phone#:

()- -

Home Phone #:

()- -

*Email Address:

*Home Address:

				City
State		Zip		APT#

Contact Details In Case of Emergency -

His/Her Name:

Phone #:

()- -

Is this appointment for your self?

Yes No

Responsible Party for Account

His/Her Name:

First name

Last name

Date of Birth:

Relationship to patient:

Address:

				City
State		Zip		APT#

*Cell Phone#:

()- -

Home Phone #:

()- -

*Email Address:

Insurance Information

Insurance Name:

Phone No#:

()- -

Primary Insured:

Date of Birth:

SS/SIN#:

Medical History

Physician’s Name:

Office Phone #:

()- -

Date of Last Exam:

1.	Are you under medical treatment now?	Yes No
2.	Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?	Yes No

If Yes, Please Explain:

Are you taking any medication(s) including non-prescription medicine?

Yes No

If Yes, What medication(s)?

4.	Have you ever taken Fen-Phen/Redux?	Yes No
5.	Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?	Yes No
6.	Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?	Yes No
7.	Do you use tobacco?	Yes No
8.	Do you use controlled substances?	Yes No
9.	Do you have or have you had any of the following?

10.	Are you wearing contact lenses?	Yes No
11.	Are you allergic to or have you had any reactions to the following?

12.

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Yes No

13.	Women Only:	a)	Are you pregnant or think you may be pregnant?	Yes No
		b)	Are you nursing?	Yes No
		c)	Are you taking oral contraceptives?	Yes No

Dental History

Previous Dentist and Location:

Date of Last Exam:

1.	Do your gums bleed while brushing or flossing?	Yes No
2.	Are your teeth sensitive to hot or cold liquids/foods?	Yes No
3.	Are your teeth sensitive to sweet or sour liquids/foods?	Yes No
4.	Do you feel pain to any of your teeth?	Yes No
5.	Do you have any sores or lumps in or near your mouth?	Yes No
6.	Have you had any head, neck or jaw injuries?	Yes No
7.	Have you ever experienced any of the following problems in your jaw?

Clicking

Pain (joint, ear; side of face)

Difficulty in opening or closing

Difficulty in chewing

8.	Do you have frequent headaches?	Yes No
9.	Do you clench or grind your teeth?	Yes No
10.	Do you bite your lips or cheeks frequently?	Yes No
11.	Have you ever had any difficult extractions in the past?	Yes No
12.	Have you ever had any prolonged bleeding following extractions?	Yes No
13.	Have you had any orthodontic treatment?	Yes No
14.	Do you wear dentures or partials?	Yes No

If yes, date of placement:

15.	Have you ever received oral hygiene instructions regarding the care of your teeth and gums?	Yes No
16.	Do you like your smile?	Yes No

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental 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 or my dependents.