Date__________________________
Patient Information
Thank you for choosing our practice for your dental needs. Please complete this form in ink. If you have any questions or concerns, do not hesitate
to ask for assistance. We will be happy to help.
Name (Please Print):
SSN ______-______-______
Title
First
MI
Last
Suffix (if any)
Address________________________________________________________________City_________________________
State___________ Zip ___________________
Home phone.#
Work phone #____________________________
Cell phone #
Date of Birth______________________________
Email Address
Do you prefer to receive calls at:  Home  Work  Cell  Any
Would you like to receive appointment reminders via email or cell phone text message? If so □ email □ cell phone
Are You:  Minor  Married  Divorced  Widowed  Single  Separated
Your employer_____________________________
Occupation
BusinessAddress_________________________________________________________City_________________________
State____________ Zip__________________
If you are a student: School/College____________________________________________City/State ___________________
How did you find out about us? Please check all that apply.
Event
Verizon Yellow Pages
Website
Internet Search
Toothbrush Sign
TV
Radio
Post Card
Word of Mouth
Employee Referral
Magazine
Patient Referral
Facebook
Specialist Referral
Other (please list):
Emergency contact
Relationship
Phone number
Responsible Party
If not yourself, name the financially responsible person___________________________________________________
Relationship to patient _________________________________________ Ph. #____________________________
Address_____________________________________________________________________________________
City___________________________________ State_____________ Zip_______________
Name or employer___________________________ Work ph. # _______________________________________
Dental Insurance Information
Name of policy holder _______________________________ Relationship to patient_______________________________
Policy holder’s date of birth______________________________ Policy holder’s S.S.N._________-_____-______________
Name of employer___________________________________________________________________________________
Name of insurance company_______________________ Insurance Ph. #________________________________________
Insurance claims address________________________________________________________________________________
Patient ID # _________________________________________ Insurance Group # _______________________________
CONFIDENTIAL
Dental History
Reason for today’s visit ________________________________________________________________________________
How often do you brush?_______________________________________How often do you floss?______________________
Name of Former Dentist ___________________________________Ph.#________________________________________
Date of last exam__________________________ Date of last dental X rays______________________________________
Do you participate in any contact sports? If so, what?__________________________________________________________
Please check any of the following conditions that apply to you:
 Bad Breath
 Clicking or popping jaw
 Sensitivity to hot
 Bleeding Gums
 Loose teeth or broken fillings
 Sensitivity when biting
 Grinding teeth
 Food collection between teeth
 Sensitivity to cold
 Jaw Pain
 Experience daytime fatigue
Medical History
Physician________________________________________________ Date of last visit______________________________
Please list all medication you are currently taking:
Are you currently taking blood thinners? Yes  No
Allergies:___________________________________________________________________________________________
__________________________________________________________________________________________________
(Women) Are you pregnant? Yes  No
Nursing? Yes No
Taking birth control pills? Yes No
Do you have a history of the following?
AIDS
Circulatory Problems
Hepatitis
Anemia
Cortisone Treatments
High Blood Pressure
Arthritis, Rheumatism
Diabetes
HIV Positive
Artificial Heart Valves
Epilepsy
Kidney Disease
Artificial Joints (Hip or knee) Fainting
Liver Disease
Asthma/Respiratory Disease GERD/Acid Reflux
Mitral Valve Prolapse
Back Problems
Glaucoma
Pacemaker
Blood Disease
Headaches
Psychiatric Care
Chemotherapy
Heart Murmur
Radiation Treatment
Cancer
Heart Problems
Scarlet Fever
Chemical Dependency
Describe ______________
Skin Rash
Stroke
Swelling of Feet/Ankle
Thyroid Problems
Tobacco/Nicotine Habit
Tonsillitis
Tuberculosis
Venereal Disease/STD
Atrial Fibrillation (Afib)
Other:__________________________________________________________________________________
S l e e p E v a l ua t i o n
Do you snore or have you been told that you snore?
Have you ever been diagnosed with sleep apnea?
Do you currently use a CPAP device?
Are you satisfied with your CPAP device?
Is your neck size larger than 15” (female) or 16.5” male?
Have you ever woken up choking and gasping?
Have you ever been told you seem to stop breathing while sleeping?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Unsure
Smile Evaluation
Are you completely happy with the appearance of your teeth/gums/smile?
If not, what don’t you like about your smile?
Would you like to discuss enhancing the appearance of your smile?
Would you like to discuss how to make your teeth WHITE?
Would you like to discuss how to make your teeth STRAIGHT?
Yes
No
Yes
Yes
Yes
No
No
No
Healthy Start Evaluation
For children under 12 years old, please check any of the following conditions that apply:
 Snoring
 Mouth breathing
 Poor ability in school
 Loud breathing at night
 Allergic symptoms
 Falls asleep watching TV
 Hyperactive
 Talks in sleep
 Wakes up at night
 ADD/ADHD
 Frequent throat infections
 Bed wetting
 Speech problemss
 Aggressive behavior/Acting out
Authorization
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been
accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to
release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the
period of such dental care to third party payers and/or health practitioners. I understand that my dental insurance carrier may pay less
than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
X_____________________
SIGNATURE OF PATIENT OR GUARDIAN (if a minor)
______________________
DATE