New Patient Information


 

Patient Information

Items marked with asterisk (*) must be completed.
 
First Name*
 
 
 
Middle Name
 
 
 
Last Name*
 
 
 
I prefer to be called (Nickname)
 
 
 
Address*
 
 
 
 
 
 
 
 
 
 
 
 
Home Phone*
 
 
 
Work Phone
 
 
 
Cell/ Other Phone
 
 
 
Email Address
 
 
 
Birth date (MM-DD-YYYY)*
 
 
 
 
 
 
 
Gender
 
 
 
Social Security Number (U.S. only)
 
 
 
 
 
 
 
If patient is a minor, give parent's or guardian's name
 
 
 
Whom may we thank for referring you to our office?
 
 
 
Other family members seen by us
 
 

Responsible Party Information

 
Full Name
 
 
 
Residence
 
 
 
 
 
 
 
 
 
 
 
 
Mailing Address (if different)
 
 
 
 
 
 
 
 
 
 
 
 
How long at this address? (years)
 
 
 
Home Phone
 
 
 
Work Phone
 
 
 
Cell/Other Phone
 
 
 
Email Address
 
 
If patient is under 18, please complete this section.
 
Previous Address
 
 
 
 
 
 
 
 
 
 
 
 
Social Security Number (U.S. only)
 
 
 
 
 
 
 
Birth date
 
 
 
 
 
 
 
Relationship to Patient
 
 
 
Employer
 
 
 
Occupation
 
 
 
Number of Years Employed
 
 
 
Spouse's Name
 
 
 
Relationship to Patient
 
 
 
Employer
 
 
 
Occupation
 
 
 
Number of Years Employed
 
 
 
Social Security Number (U.S. only)
 
 
 
 
 
 
 
Birth date
 
 
 
 
 
 
 
Home Phone
 
 
 
Work Phone
 
 
 
Cell/Other Phone
 
 
 
Email Address
 
 

Dental Insurance Information

 
Insured's Name
 
 
 
Insured's Social Security Number (U.S. only)
 
 
 
 
 
 
 
Insurance Company
 
 
 
Group Number
 
 
 
Local Number
 
 
 
Insurance Company Address
 
 
 
 
 
 
 
 
 
 
 
 
Phone Number
 
 
 
Do you have dual coverage?
 
 
 
Insured's Name
 
 
 
Insured's Social Security Number (U.S. only)
 
 
 
 
 
 
 
Insurance Company
 
 
 
Group Number
 
 
 
Local Number
 
 
 
Insurance Company Address
 
 
 
 
 
 
 
 
 
 
 
 
Phone Number
 
 

Emergency Information

 
Name of the nearest relative not living with you
 
 
 
Complete Address
 
 
 
 
 
 
 
 
 
 
 
 
Phone
 
 

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
 
Physician
 
 
 
Date of Last Visit
 
 
 
 
 
 
 
Address
 
 
 
 
 
 
 
 
 
 
 
 
Phone
 
 
Please check any of the following which apply to you, and add any relevant comments.
 
 
 
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Please check any of the following that you have had or currently have:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are there any medical conditions we have not discussed that you feel we should be aware of?

Dental History

 
General Dentist
 
 
 
Date of Last Visit
 
 
 
 
 
 
What concerns you most about your teeth?
Please check any of the following which apply to you, and add any relevant comments.
 
 
 
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If yes, who?
 
 
 
When?
 
 
 
 
 
Comment:
 
 
 
 
 
Comment:
 
 
 
 
 
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Comment:
 
 
By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.