First Name Middle Initial Last Name Date of Birth MaleFemaleOther
Home Address City
State CaliforniaAlabamaAlaskaArizonaArkansasColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code
Cell Phone Home Phone Work Phone Email
Emergency Contact Name Emergency Contact Phone
Primary Insurance Company Name Policy Number Group Number Insured’s Name Insured’s Employer Relation to PatientSelfSpouseParent
Insured’s Date of Birth
Do you want to add secondary insurance details?YesNo
Secondary Insurance Company Name Policy Number Group Number Insured’s Name Insured’s Employer Relation to PatientSelfSpouseParent
Are you having tooth pain or discomfort?YesNo
Have you been under medical care in the past 2 years?YesNo
If yes, what conditions?
Physician’s Name
Physician’s Phone
Current Medications
Allergies LatexPenicillinBleachOther
Other Allergies
Are you pregnant? YesNo Are you nursing? YesNo
Have you ever taken any bisphosphonate or any other medication for Osteoporosis (e.g. Fosamax, Boniva, Actonel, Zometa)? YesNo Have you ever been asked to pre-medicate before dental appointments? YesNo When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or because you are very tired? YesNo Have you ever had dental trauma? YesNo Have you ever had any history of TMJ (jaw joint) disorders or pain? YesNo Have you ever had radiation therapy? YesNo
Medical Conditions Heart Disease or AttackHeart MurmurStrokeArteriosclerosisMitral Valve ProlapseArtificial Heart ValveHeart SurgeryArtificial Joint (hip, knee)Kidney ProblemLiver DiseaseEpilepsy or SeizuresCancerChemotherapyChronic CoughTuberculosisAsthmaEmphysemaHigh Blood PressureHIV PositiveHepatitis A (infectious)Hepatitis BVenereal DiseaseBlood TransfusionAnemiaHemophiliaBruise EasilyDrug AddictionRheumatic FeverCold Sores / Fever BlisterSinus TroubleCortisone MedicineDiabetesUlcersFainting or Dizzy SpellsThyroid ProblemsArthritis/Rheumatism
Name Phone
I confirm that the information I have provided in this form, including my personal details and medical history, is accurate and complete to the best of my knowledge. I understand that providing incorrect or incomplete information may affect my treatment and care.Yes
