We are pleased to welcome you to our practice. Please take a few moments to fill out this form as completely as you can. If you have questions we’ll be glad to help you. We look forward to working with you in maintaining your dental health.

PATIENT INFORMATION

Name ______Preferred Name ______

Address ______City ______State______Zip______

Soc. Sec # ______Birth date ______Age ______Sex ____M ____F

_____Single _____Married _____Other Spouse/Partner’s Name (if applicable) ______

Phone Home/Cell ______Work Phone ______

Best phone number to reach you? ______Can we contact you at work? ____Y ____N

Patient Employed by ______Occupation ______

Business Address ______

Whom may we thank for referring you? ______

Person responsible for thisaccount ______

In case of emergency who should be notified? ______Phone ______

INSURANCE INFORMATION

Name of the Primary Dental Insurance: ______

ID# ______Group # ______Employer______Relationship to the patient ______DOB: ______Soc. Sec #______

Address & phone # (if different from above) ______

Name(s) of any other dependents covered under this plan ______

Name of the SecondaryDental Insurance: ______

Subscriber name ______Address ______

ID# ______Group # ______Employer______

Relationship to the Patient ______DOB: ______Soc. Sec # ______

AUTHORIZATION

Our policy requires payment in full for all services rendered at the time of your visit. If your account is not paid within 60 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and other expenses incurred in the collection of your account.

I authorize the dentist to release any information necessary to secure the payment of benefits and my insurance company to pay the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions, whether manual or electronic. I understand that I am financially responsible for all charges whether or not paid by insurance.

Patients without Insurance:

I do not have dental insurance. I understand that I am financially responsible for all charges. ______(initial here)

DENTAL HISTORY

Reason for today’s visit ______Date of last dental care ______

Former Dentist ______City/State ______Date of last dental x-rays ______

Check if you have had problems with any of the following:

Bad breath Grinding teeth Sensitivity to hot

 Bleeding gums Loose teeth or broken fillings Sensitivity to sweets

 Clicking or popping jaw Periodontal treatment Sensitivity when biting

 Food collection between teeth  Sensitivity to cold  Sores or growths in mouth

How often do you brush? ______How often do you floss? ______

MEDICAL HISTORY

Primary Care Clinic/Physician______Date of last visit ______

Have you had any serious illnesses or operations?  Yes  No If yes, describe ______

Have you ever had a blood transfusion? Yes  No If yes, give approximate dates ______

(Women) Are you pregnant?  Yes  No Nursing?  Yes  No Taking birth control pills?  Yes  No

Check if you have or have had any of the following:

 AnemiaCirculatory ProblemsHeart Murmur  Scarlet Fever

 Arthritis/RheumatismCongenital Heart DefectRheumatic Fever  Shortness of Breath

 Artificial Heart ValvesCortisone TreatmentsHigh/Low Blood Pressure  Skin Rash

StentsCough, persistentHIV+/AIDS/ARC Stroke

Artificial Joints/BonesCough up BloodJaw Problems TMJ/TMD Swelling of feet/ankles

AsthmaDiabetes/Hypoglycemia Kidney Disease  Thyroid Problems

Back ProblemsEmphysemaLiver Disease  Tobacco Habit

Bleeding problemsEpilepsyMitral Valve Prolapse  Tonsillitis

Blood DiseaseFainting/SeizuresPacemaker  Tuberculosis

Cancer/TumorsGlaucomaRadiation Treatment  Ulcer

Chemical DependencyHeadachesRespiratory Disease/COPDVenereal Disease

ChemotherapyHeart DiseaseHepatitis A B C (circle type) Depression/Anxiety

Are you currently taking any medication that thins your blood?  Yes  No If yes, name of medication? ______

Are you currently taking or have taken Boniva (Ibandronate), Fosamax (Alendronate), Reclast (Zoledronic Acid) for Rheumatoid Arthritis, Osteoarthritis, or Osteoporosis?  Yes  No If yes, Please circle.

MEDICATIONS

List medications you are currently taking or bring a list:

Please include over the counter medications.

______

______

______

I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes in the information I have provided.

Signature ______Date ______

DEDUCTIBLES AND CO-INSURANCE IS DUE IN FULL AT TIME OF TREATMENT