PATIENT INFORMATION
Name: ____________________________________________________________________
Address: _______________________________ City: ____________________ State:_________ Zip: _________________
Home Phone: ___________________ Work Phone: __________________ Ext: _______ Cellular: __________________________
Sex: [] Male [] Female
Marital Status: [] Married [] Single [] Divorced [] Separated [] Widowed
Birth Date: ____/____/_____ Age: ______ Soc. Sec: ____-____-_____ Driver’s Lic: ___________________
Employment Status: [] Full Time [] Part Time [] Retired Student Status: [] Full Time [] Part Time, Occupation:_______________________
Emergency Contact Name: ______________________________ Emergency #: ___________________
Whom may we thank for referring you to our office? ____________________________________________________
Name of primary dentist: ___________________________
RESPONSIBLE PARTY (if someone other than patient)
First Name: ______________________ Last Name: __________________ Middle Initial: __________
Address: _________________________________________ City: ____________________ State:__________ Zip: _____________
Home phone: _____________________ Cell: ______________ Work: ________________________ Ext: ____________
Birth Date: ________________ SS #: ____-___-_____ Driver’s License #: ______________________________State: ___________
Employer/Occupation: ____________________________________ Work Phone: __________________
BENEFIT INFORMATION
Primary Benefit Information
Name of Insured: _____________________________ Relationship to insured:
[] Self [] Spouse [] Child [] other
Insured Soc. Sec: ____-____-_____ Insured Birth Date: ____/____/_____ Employer: ____________________________
Ins. Company: ____________________________Subscriber I.D.:_________________________ Group #:_____________________
Address: _______________________________________ City: ____________________ State: _______ Zip: _________
Secondary Benefit Information
Name of Insured: _____________________________ Relationship to insured: [] Self [] Spouse [] Child [] other
Insured Soc. Sec: ____-____-_____ Insured Birth Date: ____/____/_____ Employer: ____________________________
Ins. Company: ____________________________ Subscriber I.D.: ________________________ Group #: _____________________
Address: _______________________________________ City: ____________________ State: _______ Zip: ______
MEDICAL HEALTH HISTORY
Do you have or have you had any of the following? (Please check any that apply)
Cancer or tumor ____
Heart disease ____
Heart murmur, mitral valve prolapse ____
Rheumatic fever or rheumatic heart disease ____
Artificial joint or valve ____
High or low blood pressure ____
Pacemaker ____
Tuberculosis or other lung problems ____
Kidney disease ____
Hepatitis or other liver disease ____
Alcoholism or dry dependency ____
Are you allergic to:
Latex materials ____
Penicillin or other antibiotics ____
Local anesthetics ("Novocain") ____
Codeine or other narcotics ____
Sulfa drugs ____
Barbiturates, sedatives, or sleeping pills ____
Aspirin ____
Other: _____________________________________
Women: May be pregnant __________ Expected delivery date: _______________
Name of your physician: __________________________________ Last Visit Date: _________________
Do you have any disease, condition, or problem not listed above?
___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
Please add any other medical or health related issues:
___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT OR GUARDIAN ___________________________________ DATE _________________
Diabetes ____
Emotional condition ____
Arthritis ____
Herpes or cold sores ____
AIDS or HIV positive ____
Migraine headaches or frequent headaches ____
Anemia or blood disorders ____
Abnormal bleeding ____
Hay fever or sinus trouble ____
Asthma ____
Fainting, epilepsy ____
Are you taking any of the following?
Aspirin ____
Anticoagulants (blood thinners) ____
Antibiotics or sulfa drugs ____
High blood pressure medicine ____
Antidepressants or tranquilizers ____
Insulin, Orinase, or other diabetes drug ____
Nitroglycerin ____
Cortisone or other steroids ____
Osteoporosis (bone density) medicine ____
Other:_____________________________________