Patient InformationName* First Middle Last Email Date* Date Format: MM slash DD slash YYYY Gender*MaleFemaleFamily Status*SingleMarriedHome PhoneWork PhoneMobile Phone*Please check the payment method you prefer* Cash Personal Check Credit Card Address* Street Address Apartment # City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactName*Relationship*Phone*Health InformationDate of Last Dental VisitReason for today’s visit*Please check all conditions that you have now or have had in the past Abnormal Bleeding AIDS or HIV+ Anemia Arthritis Artificial Joints Asthma Cancer - Chemotherapy/Radiation Diabetes - Type I or II Eating disorder Epilepsy/Seizures Fainting Glaucoma Growths Hepatitis/Jaundice Codeine Allergy Osteoporosis Kidney Disease Cardiovascular Disease Please specify Angina Arteriosclerosis Artificial heart valves Congenital heart defects Congestive heart failure Coronary artery disease Heart Attack Heart Murmur Headaches, frequent High Blood Pressure Mitral Valve Prolapse Pacemaker Rheumatic Fever Liver Disease Mental Disorders Nervous Disorders Pregnant Now?YesNoDue Date Respiratory Problems Sinus Problems GERD/Heartburn Stroke Thyroid condition Tobacco Use Tuberculosis Tumors Ulcers Sexually Transmitted Disease Penicillin Allergy Latex Allergy Other AllergiesAre you taking, or have you taken: Pondimin, Redux, or Phen-fen? Fosamax, Boniva, Actonel or other bisphosphonates? Do you use drugs or other substances for recreational purposes?YesNoPlease identify A physician or dentist has recommended that I take antibiotics before dental treatment. Please list any medications (prescription, over the counter and herbal supplements) that you are currently taking.Have you ever had any complications following dental treatment?*YesNoPlease explain:Name of PhysicianPhoneHas anyone reported that you choke or gasp for air while you are sleeping?*YesNoDo you snore?*YesNoDo you now or have you ever used CPAP?*YesNoWould you like to discuss your options for teeth whitening?*YesNoAre you open to the Doctor praying with you or for you regarding your dental care?*YesNoConsentTo the best of my knowledge, all of the preceding answers and information provided are true and correct. If I, or a patient I am responsible for, ever have any health changes, I will inform the staff at the next appointment without fail. I agreeSpouse or Responsible Party InformationThe following is for* the patient's spouse the person responsible for payment Name*Gender*MaleFemaleFamily Status*MarriedSingleChildSocial Security #Birth Date*Home PhoneWork PhoneMobile Phone*Best time to callAddress* Street Address Apartment # 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 for* the patient the person responsible for payment Employer NameOccupationPhoneAddress 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 Dental Benefits InformationPrimaryName of Subscriber First Middle Last Is subscriber a patient?YesNoSubscriber’s Birth DateID #Group #Subscriber’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 Subscriber’s Employer NameAddress: 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 subscriberSelfSpouseChildDental Benefit Plan Name and Address: Secondary Due to the unpredictable coverage of secondary dental benefits, we do not file or estimate these benefits. We will assist you with the necessary paperwork to file secondary benefits.Consent for Services and Payment Policy*I am aware that fees for dental services, which include unpaid balances, deductibles and co-payments, are due at the time of service unless other arrangements are made in advance. If I have dental benefits, I am aware that as a courtesy to me, this office will prepare forms and submit necessary documents to my benefit company. However, I realize that my benefit policy is a contract between me, my employer and the benefit company, and that I, not my benefit company, am ultimately financially responsible for all charges for treatment rendered. If my dental benefit company does not pay within 60 days, I agree to accept responsibility for any unpaid balance. I realize that accounts which are not paid within 30 days after being billed are subject to a 1% per month (12% per annum) finance charge on the unpaid balance. Overdue or unpaid accounts may be turned over to a collection agency, and I will be responsible for all of the costs of collection, including court costs, collection agency fees and attorney fees. I understand the above policies and accept responsibility for myself or patient: I agreeReferral InformationWhom may we thank for referring you to our practice?Another PatientAnother DoctorDental Office StaffInternetAdvertisementName of person referring you to our practiceNameThis field is for validation purposes and should be left unchanged. Δ