Patient's Information

Title
  • Mr.
  • Mrs.
  • Ms.
  • Dr.
  • None
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First Name
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Last Name
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Gender
  • Male
  • Female
  • Other
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Marital Status
  • Single
  • Married
  • Other
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Date of Birth
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SSN
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Driver's License #
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State
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Your Address
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City
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State
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
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Zipcode
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Home Number
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Cell Number
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E-mail Address
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Preferred Contact
  • Home Number
  • Cell Number
  • Work Number
  • Email Address
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Emergency Contact Name
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Emergency Contact Number
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Insurance Information

Subscriber's Name
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Subscriber's SSN
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Relation to Patient
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Employer
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Insurance Company
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Subscriber's DOB
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School (full-time students)
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Group
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Assignment and Release
I, the undersigned, certify that I (or my dependent) have insurance coverage with the above insurance company and assign directly to this office all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all the charges whether or not paid by insurance. I hereby authorize this office to release all information necessary to secure the payment benefits. I authorize the use of this signature and all insurance submissions.
Signature
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Date
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Office Policies

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Signature
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Date
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Dental Health History

Reason for today's visit
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Former Dentist
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Former Dentist's Phone
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Date of last dental exam
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Last time you saw a dentist
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How often do you brush?
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Date of last cleaning
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How often do you floss?
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Do you feel pain anywhere?
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Check box to indicate whether you have had any of the following conditions
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Medical Health History

Physician Name
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Physician's Phone Number
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Please list all current medications (include prescription, over-the-counter, herbal supplements) and reason for use:
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Check box to indicate whether you have had any of the following conditions
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Have you ever had any of the following conditions?
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Are you allergic to any of the following?
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WOMEN ONLY
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How did you hear about us?
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Agreement
I, the undersigned, certify that the above questions have been accurately answered to the best of my knowledge. I understand that providing incorrect information about my medical or dental history can be dangerous to my health.
Patient’s Signature / Responsible Party
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Date
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Dentist's Signature
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Date
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