• ADULT PATIENT INFORMATION

  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Format: (000) 000-0000.
  • Marital Status:*
  • Format: (000) 000-0000.

  • DENTAL HISTORY

  • Format: (000) 000-0000.
  • Frequency of dental checkups
  • Date of last dental visit:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is there any unfinished care to be completed by your dentist?*
  • Have you ever had a periodontal (gum) disease?*
  • Have you had any face or dental surgeries?*
  • Have teeth (either primary or permanent) been removed? *
  • Have you consulted an orthodontist previously?*
  • Have you noticed any changes in your bite or dental alignment recently? *
  • Please check if there is a history of any of the following:

  • MEDICAL HISTORY

    Your answers to the following questions will be helpful in selecting the safest and most effective means of providing for your dental care. All information will be kept completely confidential.
  • Last Visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Have you experienced any health problems? *
  • Any major change in your health recently?*
  • Do you have an allergy to latex?*
  • Are you currently under a physician’s care? *
  • Are you currently taking any medications?*
  • Are you allergic to any medications?*
  • Have you received a blood transfusion?*
  • Have your tonsils or adenoids been removed?*
  • Have you been in a risk group for AIDS?*
  • Please check the following:

  • INSURANCE

  • PRIMARY

     

     
  • Date of birth of subscriber:
     - -
    2 digit month, 2 digit day, 4 digit year

  • SECONDARY

  • Date of birth of subscriber:
     - -
    2 digit month, 2 digit day, 4 digit year

  • INSURANCE: To avoid misunderstandings regarding dental insurance, all professional services are charged directly to the patient and the patient is responsible for payment of fees. We will prepare necessary forms or reports to help you obtain benefits from your insurance company.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: