Title
Dr.
Mr.
Mrs.
Ms.
Miss
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
Age
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
How did you hear about us?
*
Friend
Google
Facebook
Dentist / Health Care Professional
Groupon / WagJag
Buyer's Guide
Radio Ad
Print Ad
Other
Employer
*
Occupation
*
Insurance Company
Policy Number
Certificate Number
Secondary Insurance
Policy Number
Certificate Number
Patient's Relationship to Insured
*
If Other, please explain:
Family Doctor
Family Doctor's Phone Number
(###)
###
####
Medical Specialist
Medical Specialist's Phone Number
(###)
###
####
Dentist
Dentist's Phone Number
(###)
###
####
Emergency Contact
Emergency Contact's Phone Number
(###)
###
####
Relationship to Patient
Date of Last Dental Visit
*
MM
DD
YYYY
Date of Last Cleaning
*
MM
DD
YYYY
Do you have full or partial dentures?
*
Do you have any pain in your teeth or gums?
*
Are your teeth sensitive to hot, cold, sweets or pressure?
*
Are you interested in having whiter teeth?
*
Are you happy with your smile?
*
How often do you brush your teeth?
*
More than once a day
Once a day
Every few days
Once a week
Every few weeks
Rarely
How often do you floss your teeth?
*
More than once a day
Once a day
Every few days
Once a week
Every few weeks
Rarely
Have you ever had gum surgery?
*
Do you have dental implants?
*
Are you being treated for any medical condition at present or within the past two years? If yes, please explain.
Have you been hospitalized in the past two years? If yes, please explain.
Have you recently, or are presently, taking any prescription or non-prescription drugs including herbal remedies?
Do you have a prosthetic or artificial joint?
*
Do you have any allergies to medications? Other allergies (latex or metal)? Please list.
Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction? If yes, please explain.
Do you bleed over 5 minutes when cut? Do you bruise easily? If yes, please explain.
Do you experience shortness of breath or chest pain when taking a walk or climbing stairs? If yes, please explain.
Do you have any hearing difficulties? If yes, please explain.
Do you smoke or use any other forms of tobacco? If yes, please explain.
WOMEN: Are you Pregnant?
*
WOMEN: Do you take Birth Control Pills?
*
WOMEN: Do you take a hormone supplement?
*
Indicate which of the following you presently have or have ever had:
Check all that apply
Do you currently have, or have you had in the past, any disease, condition or problem not listed above?
*
If yes, please tell us about it.
Can we send you occasional updates about your dental hygiene to your email address?
*
GENERAL RELEASE
*
By submitting this form, you certify that you have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information. You have had the opportunity to ask questions and receive any questions regarding your medical – dental history. Should there be any change in either your health status or any other information you have provided, you will advise the dental hygienist. You authorize the provider to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment. You understand that information provided from, or to, your medical doctor or another health provider may be necessary. This office has a privacy policy that protects your personal information. You understand that responsibility for payment of the dental services for yourself and your dependents is yours, and you assume responsibility for fees associated with these services.
