Please enable JavaScript in your browser to complete this form.About YouName *FirstLastI prefer to be called: *Birthdate *Age: *SS#:Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSingleMarriedDivorcedWidowedSeparatedHome Phone: *Cell/Pager#: *Work Phone:Ext.:E-mail Address: *Employer:How long there?OccupationWhere & when are the best times to reach you? *Whom may we thank for referring you? *Other family members seen by us: *Spouse InformationHis / Her name:Employer:Work Phone:Ext.:SS#:Cell #:Birthdate:Person Responsible for Account: *Work #: *Ext.:Home Phone: *Billing Address: *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRelation: *SS#:Dental Insurance Primary Dental InsuranceInsurance Company Name:Insurance Company Address:Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsurance Company Phone #:Group # (Plan, Local or Policy#):Insured's Name:Relation:Insured's Birthdate:Insured's SS#:Insured's employer:Secondary Dental InsuranceInsurance Company Name: Insurance Company Address:Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsurance Company Phone #:Group # (Plan, Local or Policy#): Insured's Name: Relation: Insured's Birthdate: Insured's SS#: Insured's employer:In the event of an emergency, who should we contact?His / Her Name: *Home Phone: *Work Phone: *Ext.:Medical HistoryDo you have a personal physician? *YesNoPhysician's Name:Phone #:Date of last visit:Your current physical health is: *GoodFairPoorAre you currently under the care of a physician? *YesNoPlease explain:Are you currently taking any prescription / over-the-counter drugs?For WOMEN: Are you taking birth control pills?YesNoAre you pregnant?YesNoAre you nursing?YesNoHave you ever had any of the following diseases or medical problems?Anemia / Radiation Treatment *YesNoHeart Surgery / Pacemaker *YesNoArtificial Bones / Joints *YesNoVenereal Disease *YesNoArtificial Valves *YesNoHepatitis *YesNoAsthma / Arthritis *YesNoHigh / Low Blood Pressure *YesNoBlood Transfusion *YesNoHIV + / AIDS *YesNoCancer / Chemotherapy *YesNoHospitalized for Any Reason *YesNoCongenital Heart Defect *YesNoKidney Problems *YesNoDiabetes / Tuberculosis (TB) *YesNoMitral Valve Prolapse *YesNoDifficulty Breathing *YesNoPsychiatric Problems *YesNoDrug / Alcohol Abuse *YesNoRheumatic / Scarlet Fever *YesNoEmphysema / Glaucoma *YesNoSevere / Frequent Headaches *YesNoHeart Murmur *YesNoShingles *YesNoFever Blisters / Herpes *YesNoSinus Problems *YesNoHeart Attack / Stroke *YesNoUlcers / Colitis *YesNoEpilepsy / Seizures / Fainting *YesNoHemophilia / Abnormal Bleeding *YesNoPlease list any serious medical condition(s) you have ever had:Are you allergic to any of the following?Aspirin *YesNoPenicillin *YesNoTetracycline *YesNoCodeine *YesNoLatex *YesNoErythromycin *YesNoOther *YesNoDental Anesthetics *YesNoPlease list any other drugs that you are allergic to:Dental HistoryWhat prompted you to seek dental care at this time? *Are your teeth sensitive to:Heat? *YesNoCold? *YesNoBiting Pressure? *YesNoDoes food constantly get stuck between certain teeth in your mouth? *YesNoDo you get frustrated because you always have something to be treated or repaired when you visit a dentist? *YesNoAre you dissatisfied with your teeth in any way? *YesNoDo you have any fillings that show in your front teeth? *YesNoDo any of your fillings show when you smile? *YesNoIf any of your mercury amalgam fillings need replacement, would you prefer to have a more natural, tooth-colored restoration instead? *YesNoDo you want to learn to control dental disease and retain your teeth? *YesNoHas the fear of discomfort kept you from regular dental visits? *YesNoAre you deeply concerned about the finances required to return your mouth to excellent dental health? *YesNoWhen was your last dental appointment?What did you have done?I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.Signature * Clear Signature Email *Submit
