Patient Information

Patient Name: Date:
Name of Parents if Minor:
Patient Gender: Male Female
Marital Status: Mr. Mrs. Single Divorced Minor
Patient Social Security: Patient Birth Date:
Email Address: Age
Work/Responsible Parent: Ext:

Health Information

Date of Last Dental Visit: Date of Last Dental X-rays:
Reason for this visit:
Former Dentist: City, State:
Check "yes" or "no to indicate if you have had any of the following:
Bad breath Yes No
Bleeding gums Yes No
Blisters on lips or mouth Yes No
Burning sensation on tongue Yes No
Chew on one side of mouth Yes No
Cigarette, pipe, or cigar smoking Yes No
Clicking or popping jaw Yes No
Dry mouth Yes No
Fingernail biting Yes No
Food collection between the teeth Yes No
Foreign objects Yes No
Grinding teeth Yes No
Gums swollen or tender Yes No
Jaw pain or tiredness Yes No
Lip or cheek biting Yes No
Loose teeth or broken fillings Yes No
Mouth breathing Yes No
Mouth pain, brushing Yes No
Orthodontic treatment Yes No
Pain around ear Yes No
Periodontal treatment Yes No
Sensitivity to cold Yes No
Sensitivity to heat Yes No
Sensitivity to sweets Yes No
Sensitivity when biting Yes No
Sores or growths in your mouth Yes No
How often do you floss?
How often do you brush?
Are you interested in any of these dental treatments?:
Invisalign Cosmetic Veneers Whitening Sedation Dentistry

Have you ever had any of the following? Please check those that apply:
Alcohol Treatment
Artificial Joints/Skeletal Implants, Valves
Back Problems
Blood Disease
Chemical Dependency
Circulatory Problems
Cortisone Treatments
Cough, Bloody persistant
Drug Treatment
Excessive Bleeding
Hay Fever
Head Aches
Head Injuries
Heart Disease
Heart Murmur
Hepatitis Type:
High Blood Pressure
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorders
Mitral Valve Prolapse
Nervous Disorders
Parkinson's Disease
Psychiatric Care
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Problems
Skin Rash
Stomach Problems
Special Diet
Swollen Feet/Ankles
Swollen Neck Glands
Thyroid Problems
Tumors of Growths
Venereal Disease
Weight Loss
Aspirin Allergy
Codeine Allergy
Barbiturates (Sleeping Pills) Allergy
Penicillin Allergy
Sulfa Allergy
Iodine Allergy
Anesthesia Allergies
Latex Allergies
Metal Allergies
Allergies Other
Are you currently pregnant? Yes No | Due Date:
Are you nursing? Yes No
Are you taking birth control pills? Yes No
Have you ever had any complications following dental treatment? Yes No
If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past two years?
Yes No
If yes, please explain:
Are you now under the care of a physician? Yes No
If yes, please explain:
Name of Physician: Phone:
Are you currently taking any medications? Yes No
If yes, please list:

Pharmacy Name:
Do you have any health problems that need further clarification? Yes No
If yes, please explain:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Patient, Parent or Guardian

Whom may we thank for referring you to our practice?
Another patient, friend Another patient, relative Dental Office Yellow Pages
Newspaper School Work Other
Name of person or office referring you to our practice:

Responsible Party Information

Who is responsible for this account?
Relationship to patient:
Social Security#: Birth Date:
Home Phone:
Work Phone: Ext.
Employer Name: Occupation:

In Case of Emergency, Contact:

Name: Relationship:
Home Phone: Work Phone:

Insurance Information

Subscriber Name: Is insured a patient? Yes No
Subscriber Date of Birth: Subscriber Social Security:
Patient's relationship to insured: Self Spouse Child Other
Insurance Plan Name and Address:

ID #: Group #:
Insured's Address:
Insured's Employer Name:
Employer Address:

Secondary Insurance Information

Subscriber Name: Is insured a patient? Yes No
Subscriber Date of Birth: Subscriber Social Security:
Patient's relationship to insured: Self Spouse Child Other
Insurance Plan Name and Address:

ID #: Group #:
Insured's Address:
Insured's Employer Name:
Employer Address:

Consent For Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1 1/2% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I understand that in the event my account becomes delinquent I agree to pay any and all collection, attorney’s and court costs necessary to clear this account balance.

I have read the above conditions of treatment and payment and agree to their content.

Signature of patient, parent or guardian/responsible party Date: Relationship to Patient:

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Recent Blog

The Oklahoma dentist that endangered his patients by exposing them to Hepatitis and HIV captured national media attention and struck fear into dental patients across the country. Fortunately, incidents like this are few and far between. In fact, the overwhelming majority of dental practices in the United States follow strict sterilization procedures to ensure the safety of their patients.

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