Patient Information and Health History
Printable New Patient Form

Patient's Name:

Last: First: MI:
Date of Birth: (xx/xx/xxxx)
Address: Gender: Male Female
Address2: Home Phone:
City: Dentist:
State: Zip: Family Physician:

Whom may we thank for referring this patient to our office?
Chief dental complaint:
Date of last complete Dental Exam:
How often does the patient clean his/her teeth? Does the patient floss? Yes No
Date of last Physical Exam: Is the patient currently under a physician's care? Yes No
May I consult the patient's Physician/Dentist about the patient? Yes No
Is the patient taking any prescriptions or over-the-counter drugs/medications? Yes No
If so, list:
Does the patient have or has he/she had allergies to medications? Yes No
If so, list:
Does the patient have or has he/she had allergies to anesthetics? Yes No
If so, list:
Does the patient have or has he/she had allergies (i.e.: Latex, food, seasonal)? Yes No
If so, list:

Does the patient have or has he/she had any of the following? (please check - Y=Yes; N=No)
Y N Asthma Y N Cortisone Y N Liver Trouble
Y N Shortness of Breath Y N Blood Thinner Y N Kidney Trouble
Y N Lip Fever Blisters Y N Thyroid Problem Y N High Blood Pressure
Y N Breath Odors Y N Major Surgery Y N Headaches
Y N Trenchmouth Y N Anemia Y N Fainting Spells
Y N Tooth Sensitivity Y N Heart Disease Y N Weight Loss
Y N Food Wedging between Teeth Y N Diabetes Y N Weight Gain
Y N High Cholesterol Y N Hepatitis Y N Chronic Tiredness
Y N Teeth Straightened Y N Arthritis Y N Low Blood Pressure
Y N Clotting Problems Y N Rheumatic Fever Y N Excessive Thirst
Y N Bleeding Problems Y N Artificial Joints Y N Nervous Tensions
Y N Autoimmune Disorder Y N Seizures Y N Stress
Y N Previous Periodontal (Gum) Tx Y N HIV
If you have answered "Yes" to any of the above, please explain:
Does the patient have any other medical or dental problems and/or conditions? Yes No
If so, list:
Does the patient have any information/x-ray, etc. to bring to us? Yes No
Whom should we contact in an emergency?
Name: Relationship: Phone:
Please bring all information to your first visit.
PERIODONTAL
  Within Normal Limits  
   Concerns
ORAL CANCER SCREENING      +   -
Reviewed
Date

Patient Financial/Insurance Information
Primary Responsible Party (Patient or Parent/Guardian if Patient is a Minor)
Primary Responsible Party: Date Of Birth: (xx/xx/xxxx)
Relationship: SS#:
Marital Status: Medical Insurance Co.:
Address: Medical Insurance Co. Phone #:
City: State: Zip: Dental Insurance Co.:
Home Phone: Dental Insurance Co. Phone #:
Cell Phone: Dental Insurance Co. Address:
Work Phone: Dental Insurance Co. City:
Email: Dental Insurance Co. State: Zip:
Employer: Subscriber Name:
Employer Address: Subscriber ID Number:
Employer City: Group Number:
Employer State: Zip:        Orthodontic Coverage? Yes No

Secondary Responsible Party (Spouse or Parent/Guardian)

Secondary Responsible Party: Date Of Birth: (xx/xx/xxxx)
Relationship: SS#:
Marital Status: Medical Insurance Co.:
Address: Medical Insurance Co. Phone #:
City: State: Zip: Dental Insurance Co.:
Home Phone: Dental Insurance Co. Phone #:
Cell Phone: Dental Insurance Co. Address:
Work Phone: Dental Insurance Co. City:
Email: Dental Insurance Co. State: Zip:
Employer: Subscriber Name:
Employer Address: Subscriber ID Number:
Employer City: Group Number:
Employer State: Zip:        Orthodontic Coverage? Yes No


INSURANCE: Your signature allows us to bill your insurance company for services rendered. Any account balance remaining outstanding after insurance has paid is the responsibility of the patient/responsible party.

Monthly statements will be sent to the person who signs below. We reserve the right to check the credit history of any party in default, or those individuals signing this contract.

I certify that the above Patient information is correct to the best of my knowledge and I agree to notify this office of any changes in the Patient's health/financial history during the course of treatment.
I consent Yes No (Parent or Guardian if Patient is a Minor)
Type Name:
Today's Date: (example: March 1, 2010)
Appointment Date & Time: (example: March 1, 2010 10 am)