Patient Forms

Patient Information

Name*

First Middle Last

Preferred Name

Date of Birth

Social Security Number

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone

Mobile Phone

Work Phone

Email*

Responsible Party Information

Name

First Middle Last

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Social Security Number

Relationship to Patient

Employer

Occupation

Status

Spouse's Name

First Middle Last

Employer

Occupation

Status

Insurance Information

Policy Holder's Name

Date of Birth

Phone

Employer

Insurance Company

Group #:

ID #:

Do you have secondary insurance?

Yes
No

If yes:

Policy Holder's Name

Date of Birth

Phone

Employer

Insurance Company

Group #:

ID #:

Medical History

Name of Physician

Whom may we contact in case of emergency?

Do you have, have you had, or ever been treated for any of the following? Check all that apply.

Please select any of the following which may apply to you:

Have there been any changes in your medical history in the last 2 years?

Yes
No

Are you currently under the care of a physician?

Yes
No

Have you ever had any surgical operation of any kind?

Yes
No

Have you been advised by a physician of the need for any type of surgery or treatment?

Yes
No

Have you ever had an allergic reaction or been told not to take any medication?

Yes
No

Have you ever had an allergic reaction to latex?

Yes
No

Are you taking any prescription medications of any kind?

Yes
No

Are you taking any over the counter medications of any kind?

Yes
No

If yes to any of the above, please list or explain:

Do you use any tobacco products?

Yes
No

If yes, what kind and amount?

Please verify all information on this form is accurate*

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.

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Patient Information

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Medical History

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