WELCOME: PLEASE LET US KNOW ABOUT YOU….        If Possible, We will verify insurance information prior to your visit,  this will save you time…..

Patient’s Full Legal Name:_______________________________________Nickname:____________________ 

Date of Birth of Patient:__________________________________________

Mailing Address of Patient:_______________________________________

Social Security # of Patient:______________________________________

Gender of Patient:_________________________________________________

RESPONSIBLE PARTY INFORMATION:

Responsible Party Full Name:_____________________________________

Responsible Party Phone Number:________________________________

Responsible Party Address:

Responsible Party Email:

___________________________________________________________________

Responsible Party Date of Birth: __________________________________

Responsible Party Social Security#:______________________________

INSURANCE INFORMATION:

Name of the Insured:_____________________________________________

Date of Birth:__________  Social Security #_________________________

Group Number:___________________Policy#:_______________________

Effective Date:________________Subscriber ID:____________________

Employer Name & Phone #:______________________________________

Employer Address:_______________________________________________

Insurance Company name_______________________________________

Insurance Company Phone Number:_____________________________

EMERGENCY INFORMATION:

Emergency Contact Person:_____________________________________

Relationship to Patient:_________________________________________

Phone Number: ____________________Email:_______________________

PLEASE INDICATE “YES” OR “NO” TO THE FOLLOWING QUESTIONS FOR THE PATIENT:

Have you seen a Dentist in the Last 6 months? YES________NO_______

Do you think you have cavities or gum problems that need treatment or have you been told they need treatment? YES___________NO_________

IF YES Please Explain:____________________________________________

Have you had any injuries to your teeth, jaws or head? YES_____NO____

Do you see a Physician? YES___________NO___________

Name and Address of Physician:__________________________________

Do you see a Dentist? YES_____________ NO___________

Do you have medical, physical, psychiatric conditions that require ongoing medical doctor visits and/or treatment? YES_______ NO_____

If Yes Please Explain:____________________________________________

Have your Wisdom Teeth been Removed? YES___________NO________

Problems with Food trapped between Teeth? YES ________ NO _______

Is all your current Dental work Completed? YES_________NO__________

Do you have a history of bleeding problems? YES_________NO________

If YES Please Explain: ___________________________________________

Do you have HIV/AIDS?  YES _________  NO__________

Do you have Kidney Disease? YES ________ NO _______

Do you have Sinus Trouble? YES _________ NO _______

Do you take Bisphosphonates (Fosamax or Boniva)? YES ______ NO____

If you facial appearance could be changed, what would you change?_______________________________________________________________________

If your teeth could be moved or changed, what would you change?

_______________________________________________________________________________________________________________________________________________

Do you have any allergies to medication, food or environmental substances? YES ___________ NO ____________

If Yes Please Explain:__________________________________________

Are you pregnant or is there a chance you might be pregnant: YES_______ NO______

Do you take any prescription or over-the-counter medications:

YES_______NO_______

I certify this information is true and correct to the best of my knowledge. I understand that I am responsible for financial charges.

Signature:_______________________________________________Date:____________________