Step 1 of 6 16% Patient InformationPatient First Name*Patient Last Name*Today's Date* Date Format: MM slash DD slash YYYY Social Security Number*Date of Birth* Date Format: MM slash DD slash YYYY Email* Gender*MaleFemaleMarital Status*SingleMarriedSeparatedDivorcedHome Phone*Work Phone*Cell Phone*Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Health InformationDate of Last Dental Visit Date Format: MM slash DD slash YYYY Reason for this VisitHave you ever had any of the following? Please check all that apply. AIDS Allergies Arthritis Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease Heart Murmur Hepatitis High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Pregnancy Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Stroke Tuberculosis Tumors Ulcers Venereal Disease Codeine Allergy Penicillin Allergy Sulfa Allergy Latex Allergy Do you take ASPIRIN daily? Have you been told to premed for a dental procedure? If Pregnant, Due Date? Date Format: MM slash DD slash YYYY Have you ever had any complications following a dental treatment?NoYesIf yes, please explainHave you been admitted to a hospital or needed emergency care during the past two years?NoYesIf yes, please explainName of PhysicianPhone Number of PhysicianMedicationsPlease list any medications you are currently taking.NameStrengthHow OftenPurpose of Med BisphosphonatesAre you taking any of the following or any other Oral or IV Bisphosphonates Etidronate (Didronel) : Tx for Paget's Disease Tiludronate (Skelid): Tx for Paget's Disease Alendronate (Skelid): Tx for Osteoperosis Risedronate (Actonel): Tx for Osteoperosis Ibandronate (Boniva): Tx for Osteoperosis Pamidronate (Aredia): Tx for Bone Metastasis Zoledronate (Zometa): Tx for Bone Metastasis If you are taking any Bisphosphonates please list them below with the dose and reason for medication. Please notify your Dental Assitant and Dentist during your initial visit.Referral InformationWho may we thank for referring you to our practice? Another patient, friend Another patient, relative Dental Office Yellow Pages Newspaper School Work Name of person or office referring you to our practice Spouse or Responsible Party InformationThe following is forThe patient's spouseThe person responsible for paymentFirst NameLast NameGenderMaleFemaleMarital StatusSingleMarriedSeparatedDivorcedSocial Security NumberDate of Birth Date Format: MM slash DD slash YYYY Home PhoneWork PhoneExtensionBest Time to CallMorningAfternoonEveningEmail Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment InformationThe following is forThe patient's spouseThe person responsible for paymentEmployer NameOccupationEmployer Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance InformationPrimaryFirst Name of InsuredLast Name of InsuredIs Insured a Patient?YesNoInsured Date of Birth Date Format: MM slash DD slash YYYY ID NumberGroup NumberInsured's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insured's Employer NameInsured's Employer Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient's Relationship to InsuredSelfSpouseChildInsurance Plan NameInsurance Plan Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SecondaryFirst Name of InsuredLast Name of InsuredIs Insured a Patient?YesNoInsured Date of Birth Date Format: MM slash DD slash YYYY ID NumberGroup NumberInsured's Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insured's Employer NameInsured's Employer Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient's Relationship to InsuredSelfSpouseChildInsurance Plan NameInsurance Plan Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.Name of Patient, Parent, or Guardian First Last SignaturePlease wait until you reach the confirmation page before closing your browser or your form may not be submitted correctly*I understand
