Patient Form

ABOUT YOU
Birth Date:
Permission, to send TEXT appointment reminders?
Yes No
Last visit date:

SPOUSE INFO

Birth Date:
ACCOUNT INFORMATION
Birth Date:
PRIMARY DENTAL INSURANCE
Subscriber's Birthdate:
HOW DID YOU FIND US?
MEDICAL HISTORY
Are you under the care of a physician? YesNo
Please check your response to indicate if you have or have had any of the following:
Allergy Anesthetics
Allergy Aspirin
Allergy Codeine
Allergy Latex
Allergy Metals
Allergy Other
Allergy Penicillin
Allergy Seasonal
Allergy Sulfa Drug
Anemia
Arthritis
Artificial Joints
Asthma
Autoimmune Disease
Blood Disease
High Blood Pressure
Low Blood Pressure
Cancer
Diabetes
Emphysema
Epilepsy
Excessive Bleeding
Fainting/Dizziness
Glaucoma
Growths
Head Injuries
Heart Angina
Heart Attack
Heart Damaged Valves
Other Heart Disease
Heart Disease
Heart Endocarditis
Heart Failure
Heart Murmur
Heart Pacemaker
Heart Rheumatic
Heart Transplant
Heart Valve Prolapse
Cardiovascular
Prosthetic Valve
Hepatitis
High Colesterol
HIV/AIDS
Jaundice
Kidney Disease
Liver Disease
Liver Transplant
Mental Disorder
Nervous Disorder
Neroulogical Disorder
Pre-Medicates
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problem
STD
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
Arteriosclerosis
Systemic Lupus Erythematosus
Bronchitis
Chest Pain Upon Exertion
Chronic Pain
Eating Disorder
Malnutrition
Gastrointestinal Disease
G.E. Reflux/Persistant Heartburn
Thyroid Problems
Sleep Disorder
Mental Health Disorder
Recurrent Infections
Night Sweats
Osteoporosis
Persistant Swollen Glands in Neck
Severe Headaches/Migraines
Severe or Rapid Weight Loss
Excessive Urination
Have you had a serious illness, operation or been hospitalized in the past 5 years? YesNo
Are you taking or have you recently taken any perscription or over the counter medicine(s)? YesNo
Have you had an orthopedic total joint replacement? YesNo
If yes, please provide date:
Do you use controlled substances (drugs)? YesNo
Do you use tobacco (smoking, snuff, chew, bidis)? YesNo
By checking this box, I acknowledge that above information is correct and I understand it is my responsibility to inform the office of any changes in my health as soon as possible.
Disclaimer

I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental team to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

In the event that payment in full for charges incurred is not made, I agree to pay all costs of collection including

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Office Financial Policy.
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