Patient Name:
How did you hear about us?
(last)
(first)
(middle)
Preferred Name (Nickname):
What would you like done TODAY?
Address:
Does anything bother you about your teeth?
(city)
Phone:
(
(state)
)
(
(home)
(
Does dental treatment make you nervous? r NO
(zip)
)
r YES
Date of last dental visit:
(work)
)
Date of last complete dental x-ray:
(cell)
Email address:
@
Last dentist:
Birthday (mm/dd/yyyy):
Check one:
City:
Why did you leave the office?
r Child r Single r Married
INSURANCE INFORMATION:
Patient's Name (if minor Father's):
Employer:
Driver's License:
Spouse (if minor Mother's)
Employer:
Driver's License:
Primary Insurance:
Subscriber:
Subscriber's SS#:
Subscriber's Birthday:
Secondary Insurance:
Subscriber:
Subscriber SS#:
Subscriber's Birthday:
r Separated
r Widow
MEDICAL HISTORY:
Your physician:
Are you Pregnant? r Yes
r No
months
Any medical problems NOW?
Check if you ever had any of the followings:
r
r
r
r
r
r
r
r
Cancer
Diabetes
High blood pressure
Heart condition
Blood clotting problem
Epilepsy
Artificial joint or valve
Hepatitis
r
r
r
r
r
r
r
r
TB
AIDS or HIV
Substance abuse
Smoker
Orthodontic Treatment
Gum Disease
TMJ
High stress life
Has your doctor ever told you to "pre-med" before a dental visit?
Any drug allergies?
Who is responsible for this Account?
Current medications you are taking?
"The highest compliment our patient can give us is the referral of their friends and family" Visit us at www.RcDentalOffice.com
r No
r Yes