CONFIDENTIAL PATIENT INFORMATION
                                                               PLEASE PRINT

DATE ________________
NAME___________________________________________ BIRTHDATE ___________________ 
CHECK BOX ___MINOR / DEPENDENT _____SINGLE _____MARRIED _____DIVORCED / SEPARATED / WIDOWED
ADDRESS________________________________________________ CITY,STATE,ZIP_________________________________________
SOCIAL SECURITY NUMBER ________________________________________
HOME PHONE___________________________ CELL ____________________
NAME OF EMPLOYER__________________________________________________
ADDRESS OF EMPLOYER____________________________________________ WORK PHONE_____________________________
SPOUSE OR PARENT’S NAME ______________________________________
SPOUSE OR PARENT’S EMPLOYER _____________________WORK PHONE_________
WHOM MAY WE THANK FOR REFERRING YOU? ______________________________________________________________________
PERSON TO CONTACT IN CASE OF AN EMERGENCY ________________________________ PHONE ___________________________ RESPONSIBLE PARTY (IF DIFFERENT FROM ABOVE)
NAME OF PERSON RESPONSIBLE FOR THIS ACCOUNT ______________________________ RELATIONSHIP TO PATIENT _________________
ADDRESS (IF DIFFERENT FROM ABOVE)__________________________________________ HOME PHONE ______________________________
SOCIAL SECURITY NUMBER ________________________________________ BIRTHDATE ___________________________________________
EMPLOYER ______________________________________________________ WORK PHONE ___________________________________________
? DENTAL INSURANCE INFORMATION
NAME OF INSURED / EMPLOYEE___________________________________________ RELATIONSHIP TO PATIENT___________
SOCIAL SECURITY NUMBER__________________________________ BIRTHDATE_____________________________
NAME OF EMPLOYER_______________________________________________ WORK PHONE______________________________
ADDRESS OF EMPLOYER_________________________________________ CITY, STATE, ZIP_____________________________
INSURANCE COMPANY__________________________________ GROUP #____________________________
INS. CO. ADDRESS________________________________________________ CITY, STATE, ZIP______________________________ SECONDARY DENTAL INSURANCE IF YOU HAVE MORE THAN ONE DENTAL INSURANCE
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NAME OF INSURED / EMPLOYEE___________________________________________ RELATIONSHIP TO PATIENT___________
SOCIAL SECURITY NUMBER__________________________________ BIRTHDATE___________________________
NAME OF EMPLOYER_______________________________________________ WORK PHONE______________________________
INSURANCE COMPANY__________________________________ GROUP #____________________________
INS. CO. ADDRESS________________________________________________ CITY, STATE, ZIP______________________________ PATIENT MEDICAL HISTORY
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MEDICAL DOCTOR ________________________________________________ OFFICE PHONE _________________________________
YES NO
1. ARE YOU UNDER MEDICAL TREATMENT NOW? ___ ___ 6. ARE YOU ALLERGIC TO OR HAD ANY REACTION
TO THE FOLLOWING?
2. HAVE YOU BEEN HOSPITALIZED FOR ANY YES NO
SURGERY OR SERIOUS ILLNESS WITHIN THE LOCAL ANESTHETIC ___ ___
LASTS 5 YEARS? ___ ___ NOVACAINE OR OTHER
3. ARE YOU TAKING ANY MEDICATIONS, PENICILLIN OR OTHER ANTIBIOTIC ___ ___
INCLUDING NON-PRESCRIPTION MEDICINE? ___ ___ SPECIFY __________________
LIST: _______________________________ MERCURY OR OTHER METAL ___ ___
_______________________________ LATEX ___ ___
________________________________ OTHER ALLERGIES
LIST: __________________________
4. ARE YOU CURRENTLY TAKING ANY BLOOD ___ ___
THINNER? __________________________
7. WOMEN ONLY
5. DO YOU USE TOBACCO? ____ ____ A. ARE YOU PREGNANT? ___ ___
B. ARE YOU NURSING? ___ ___
C. ARE YOU TAKING BIRTH
CONTROL PILLS? ___ ___
DO YOU HAVE ANY OF THE FOLLOWING?
YES NO YES NO YES NO
____ ____ HIGH BLOOD PRESSURE ____ ____ AIDS OR HIV INFECTION ____ ____ ANEMIA
____ ____ HEART ATTACK ____ ____ CARDIAC PACEMAKER ____ ____ HEPATITIS / JAUNDICE
____ ____ RHEUMATIC FEVER ____ ____ HEART MURMUR ____ ____ STROKE
____ ____ HEART PROBLEMS ____ ____ MITRAL VALVE PROLAPSE ____ ____ TUBERCULOSIS
____ ____ ASTHMA ____ ____ EMPHYSEMA ____ ____ RADIATION THERAPY
____ ____ RESPIRATORY PROBLEMS ____ ____ EPILEPSY / CONVULSIONS ____ ____ CANCER
____ ____ LEUKEMIA ____ ____ SEXUALLY TRANS DISEASE ____ ____ LIVER DISEASE
____ ____ DIABETES ____ ____ JOINT REPLACEMENT/IMPLANT ____ ____ KIDNEY DISEASES PATIENT DENTAL HISTORY
YES NO YES NO
1. DO YOUR GUMS BLEED WHILE BRUSHING OR FLOSSING? ___ ___ 8. DO YOU HAVE FREQUENT HEADACHES? ___ ___
2. ARE YOUR TEETH SENSITIVE TO HOT OR COLD? ___ ___ 9. DO YOU CLENCH OR GRIND YOUR TEETH? ___ ___
3. ARE YOUR TEETH SENSITIVE TO SWEET OR SOUR? ___ ___ 10. DO YOU BITE YOUR LIPS OR CHEEKS? ___ ___
4. DO YOU FEEL PAIN IN ANY OF YOUR TEETH? ___ ___ 11. HAVE YOU EVER HAD ANY DIFFICULT
5. DO YOU HAVE ANY SORES OR LUMPS IN YOUR MOUTH? ___ ___ EXTRACTIONS IN THE PAST? ___ ___
6. HAVE YOU HAD ANY HEAD, NECK, OR JAW INJURIES? ___ ___ 12. HAVE YOU HAD ANY ORTHODONTIC WORK? ___ ___
7. HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING 13. HAVE YOU HAD ANY PROLONGED BLEEDING
PROBLEMS IN YOUR JAW? FOLLOWING EXTRACTIONS? ___ ___
A. CLICKING? ___ ___ 14. HAVE YOU EVER HAD INSTRUCTIONS ON
B. PAIN (JOINT, EAR, SIDE, OF FACE)? ___ ___ THE CORRECT METHOD OF BRUSHING?___ ___
C. DIFFICULTY IN OPENING OR CLOSING? ___ ___
? AUTHORIZATION AND RELEASE
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 the third party payors and/or health practioners. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. 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.
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Signed __________________________________________________________ Date ______________________
PATIENT OR PARENT/GUARDIAN IF PATIENT IS A MINOR

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