Online Patient Information Form Whom may we thank for referring you? Name of Previous Dentist Last Dental Exam MM slash DD slash YYYY Patient InformationPatient Name(Required) First Last Nickname Social Security #(Required) Birthday(Required) MM slash DD slash YYYY Age(Required)GenderMaleFemaleAddress(Required) Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home/Cell Phone(Required)Work PhoneEmployer(Required) Occupation(Required) Marital StatusMarriedSingleDivorcedWidowedSpouse's Name First Last Emergency Contact(Required) First Last Relationship Phone(Required)Patient's Email Financial ResponsibilityI accept full financial responsibility for dental treatment and cleanings for my family. I understand my insurance will be filed as a courtesy and the amount insurance does not pay and any deductibles and or co-pays will be my responsibility at the time services are rendered. If you DO NOT have dental insurance the full amount will be due at time of service.Today's Date(Required) MM slash DD slash YYYY Name(Required) First Last Consent(Required) I agree to the Financial Responsibility policy.Dental InsuranceIf you have dental insurance please give front desk your insurance card. We need the following:Subscriber/Policy Holder Date of Birth MM slash DD slash YYYY Social Security Number Medical HistoryDo you have any current health problems(Required)NoYesAre you under a physician’s care now?(Required)NoYesAre you currently taking medications?(Required)NoYesIf so, please list all medications and the reason for taking the medications.Have you ever taken Bisphosponates (Fosamax)(Required)NoYesDo you smoke?(Required)NoYesIf yes, how much per day? Are you pregnant?(Required)NoYesName of Family Physician First Last Physician's PhoneCHECK ALL OF THE FOLLOWING YOU HAVE HAD OR HAVE AT THIS TIME:Have you had (column one) Heart Attack Heart Disease Heart Murmur Rheumatic Fever High Blood Pressure Hemophilia Artificial Heart Valve Fainting/Dizzy Spells Epilepsy/Seizures Sickle Cell Disease Anemia Stroke Kidney Trouble Cosmetic Surgery Have you had (column two) Yellow Jaundice Hepatitis A (infectious) Hepatitis B (serum) Hepatitis C Liver Disease Glaucoma Drug Addiction Tuberculosis (TB) Allergies/Hives Pain in Jaw Joints Psychiatric Treatment Venereal Disease Pneumonia Blood Transfusion Have you had (column three) Fever Blisters Chemotherapy Nervousness Cancer/Leukemia Hay Fever Diabetes I and II Scarlet Fever Arthritis Emphysema Bleeding Problems Bruise Easily Sinus Trouble Cancer Radiation Ulcers Thyroid Disease Have you had (column four) Previous Infective Endocarditis Rheumatism Cortisone Medication HIV/AIDS Alcoholism Asthma Congenital Heart Lesions Alcoholism Heart Pacemaker Heart Surgery Artificial Joint/Hip/Knee Hearing Loss Venereal Disease (Syphilis, etc) Wear Partial/Dentures Eating Disorder Medical AlertsMedical Alerts (Column 1) Allergic to Asprin Allergic to Codine Heart Problems Medical Alerts (Column 2) Mitral Valve Prolapse Allergic to Erythromycin Latex Medical Alerts (Column 3) Allergic to Penicillin Allergic to Sulfa HIV Positive Medical Alerts (Column 4) Pre-Medication Required Prior Hepititis Pre-Medication Required Details Additional InformationAdditional CommentsPatient Name(Required) First Last E-Signature(Required) Everything in this form is true to the best of my knowledge and belief.Today's Date(Required) MM slash DD slash YYYY
