Print Form
Welcome
Patient Information
Date
SS/HIC/Patient ID #
Patient
Address
city
State
Zip
E-mail
Sex
M
F
Age
Birthdate
Married
Widowed
Single
Minor
Seperated
Divorced
Partnered for
Years
Occupation
Patient Employer/School
Employer/School Address
Employer/School Phone (include area code)
Spouce's Name
Birthdate
SS#
Spouce's Employer
Whom may we thank for referring you?
Dental Insurance
Who is responsible for this account?
Relationship to patient
Insurance Co.
Goup #
Is patient covered by additional insurance?
Yes
No
Subscriber's Name
Birthdate
SS#
Relationship to patient
Insurance Co.
Group #
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with
Name of Insurance Company(ies)
and assign directly to
Dr.
all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or benefits payable for related services. This consent will end when my current treatment plan is completed or one year from th date signed below.
Signature of Patient, Parent, Guardian or Personel Representative
Please print name of Patient, Parent, Guardian, or Personal Representative
Date
Relationship to Patient
Phone Numbers
Home
Work
Ext
Cell Phone
Spouse's Work
Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT
(Specify someone who does not live in your household)
name
Relationship
Home Phone
Work Phone
Dental History
Reason for today's visit:
Former Dentist
City/State
Date of last dental visit
Date of last dental X-rays
Please select "Yes" or "No" to indicate if you have had any of the following:
Bad breath
Yes
No
Bleeding gums
Yes
No
Blisters on lips or mouth
Yes
No
Burning Sensation on tongue
Yes
No
Chew on one side of mouth
Yes
No
Cigarette, pipe, or cigar smoking
Yes
No
Clicking or popping jaw
Yes
No
Dry mouth
Yes
No
Fingernail biting
Yes
No
Food collection between the teeth
Yes
No
foreign objects
Yes
No
Grinding teeth
Yes
No
Gums swollen or tender
Yes
No
Jaw pain or tiredness
Yes
No
Lip or cheek biting
Yes
No
Loose teeth or borken fillings
Yes
No
Mouth Breathing
Yes
No
Mouth pain, brushing
Yes
No
Orthodontic treatment
Yes
No
Pain around ear
Yes
No
Periodontal treatment
Yes
No
Sensitivity to cold
Yes
No
Sensitivity to heat
Yes
No
Sensitivity to sweets
Yes
No
Sensivity when biting
Yes
No
Sore or growths in your mouth
Yes
No
How oftden do you floss?
How often do you brush?
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