New Patients Form
Today's Date: Saturday 04th September 2010
Patient Name:  
Patient Address:  
City: State: City:
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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