New Patients Form
Today’s Date: Monday 10th August 2015
Patient Name:
Patient Address:
City: State:

Zipcode:
Patient SS#: Date of Birth:

Sex: M

F
Home Phone: Business Phone: Ext:
Cell Number: Beeper Number:
Can we call you at work? Yes

No

 Email Address:*
In Case of Emergency, contact:
Relationship of Patient:
 Phone:
Marital Status : 

Single 


Married


Separated   

Divorced   

Widow   

Widower

Patient/Parent Employed by:
Occupation:

How longed employed:
Primary Dental Insurance Secondary Dental Insurance
Ins. Co. Name:
 Ins. Co. Name:
Address:  Address: 
City: 
State:

Zip:
 City: 

State:

Zip:
Group/Policy Number:
 Group/Policy Number:
Employer:  Employer: 
Business Address:
 Business Address:
Employee:  Employee: 
Employee SS#:
 Employee SS#:
Employee Date of Birth:  Employee Date of Birth: 
Relationship to Patient:
 Relationship to Patient:
Your Smile
Is there anything about your smile you would like to change?
Do you take nutrition supplements:
 Do they work? Yes


 No
Your Visit Today
How did you learn of my office?:
What prompted you to seek dental care at this time?
Are you having pain, discomfort or sensitivity at this time?:   Yes

 No

 
If so, please explain
Health History
It is IMPORTANT that we know about your Medical/Dental History. These facts have a direct bearing on your dental health.
When was your last dental check-up?

Name of your last dentist:
 Why did you leave?
What did you most like about your previous dentist?:
Do you feel very nervous about dental treatment?: 
Do you smoke?  Yes

 No

 If yes, how much?:
Do you grind your teeth?: Yes

 No

     Do you wear any type of dental appliance?:
Have you been a patient in the hospital during the past two years?: Yes

 No
If yes, for what?:
Have you been under the care of a medical doctor during the past year?:
Physician’s Name:
Address:
Phone:
Cardiologist’s Name:
Address:
Phone:
Are you taking any medication, drugs or vitamins at this time?: Yes

 No

   If yes, please list:
Rx 1. What for?
Rx 2. What for?
Rx 3. What for?
Rx 4. What for?
Rx 5. What for?
Rx 6. What for?
Rx 7. What for?
Rx 8. What for?
Rx 9. What for?
Rx 10. What for?
Do you or have you ever taken any medications for osteoporosis, such as bisphosphinates? Yes

No
Do you need to be premedicated prior to dental appointments?: Yes

 No

Rx:
If yes, why?:
Do you, or have you ever had any of the following symptoms?
Headaches


Facial Pain (non specific)
Pain in your Jaw


Tender Sensitive Teeth (biting)
Noises in your Jaw (opening)


Difficulty Chewing
Noises In Your Jaw (closing)


Postural Problems
Limited Opening


Paresthesia of Fingertips (tingling)
Jaw Locking


Thermal (hot/cold) Sensitivity
Earache


Trigeminal Neuralgia
Ear Congestion


Bells Palsy
Vertigo (dizziness)


Insomnia
Tinnitis (ringing in ears)


Snoring
Dysphagia (difficulty swallowing)


Sleep Apnea
Loose Teeth


Do you suffer from neck, shoulder or back pain?
Clenching


Grinding
Are you allergic or have you reacted adversely to any of the following medications? If so, please tick.

Aspirin
Amoxicillin
Tetracycline
Xylocaine
Local Anesthetic

Nitrous Oxide
Sulfa Drugs
Penicillin
Sleeping Pills
Latex

Codeine
Erythromycin
Valium
Cortisone Medicine		 Other Antibiotics
Please list any other medications or substances you are aware of being allergic to:
Tick any of the following which you have had or have at present:

Mitral Valve Prolapse
Artificial Joints (Hip, Knee)
Sinus Trouble
Hepatitis Type A (infectious)

Heart Disease of Attack
Allergies or Hives
sted HIV Positive
Hepatitis Type B (serum) or other

Heart Murmur: Functional/Non-Functional
Liver Disease
Anemia

Diabetes
Drug or Alcohol Addiction
Stroke
Kidney Trouble

Radiations Therapy
Thyroid Disease
Blood Transfusion
Angina Pectoris

High Blood Pressure
Ulcers
Chemotherapy
Arthritis

Fever Blisters
Rheumatic Fever
Cosmetic Surgery
Cancer or Leukemia

Cold Sores
Epilepsy/Seizures
Emphysema
Congenital Heart Lesions

Glaucoma
Fainting/Dizzy Spells
Scarlet Fever
Chronic Cough

Rheumatism
Bruise Easily
Nervousness
Artificial Heart Valve

Tuberculosis (TB)
Hemophilia
Asthma
Heart Pacemaker

Heart Surgery
Psychiatric Treatment
For Women Only
Are you pregnant?: Yes

 No

If yes, what month?:
Are you taking birth control pills?: Yes

 No

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE.
CONSENT:

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. The undersigned hereby authorizes Doctor to take
x-rays, study models, photographs or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Doctor
to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with

(Name of Patient)

authorize and consent that Doctor choose and employ such assistance as deemed fit. I understand that responsibility for payment for Dental Services provided in this
office for myself or my dependants is mine, due payable at the time services are rendered unless financial arrangements have been made. I further understand that a 1 1/2%
finance charge (18% annually) may be added to any balance over 90 days. In the event of default, I (We) promise to pay legal interest on the indebtedness together and with such
collection costs and reasonable attorney fees as may be required to effect collection of this note.
Patient:

Date:

Witness:
Parent or Responsible Party:
Relationship to Patient:
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that, under HIPAA, I have certain rights to privacy regarding my potential health information. I understand that this information can and will be used to:

 

Conduct, plan and direct my treatment among healthcare providers involved in that treatment,directly or indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations.

I have had the opportunity to read the complete Notice of Privacy Practices. I understand that changes to notice of Privacy Practices may occur and that I may contact this
organization to obtain a current copy.

I understand that I may request in writing that you restrict how information is disclosed.Patient Name: Relationship to Patient:
Date:
Confirmation code: *

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