Patient Information
First Name
Last Name
Birth Date
Address (Continued)
Primary Phone
Secondary Phone
What is your medical doctor's name
Who were you referred by?
Drivers License Number
Employer Phone
General Insurance Information
Primary Dental Insurance Information
Business Address
Address (Continued)
Plan Name
Insurance Company
Insurance Company Address
Insurance Company Address (Continued)
Insurance Company Phone
Group Number
Group Name
Insured Name
Insured Relation
Insured Birth Date
Insured Address
Insured Address (Continued)
Insured Phone
Insured Social Security Number
Policy I.D. Number
Health History

To our patients: Although dentists primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care, that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

What is your reason for visiting our practice?
0 /
Have you had or do you currently have?select all that apply
Is there a FAMILY history of?select all that apply
Patient Dental Historyselect all that apply
Name of previous dentist and location
Date of last exam
Medications Allergies
Medications you are currently takingselect all that apply
Are you allergic or had a reaction to:select all that apply
Please list any allergies other than drug allergies:
0 /
In case of emergency, contact
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relation

Payment is due in full at the time of treatment unless prior arrangements have been approved.

This office accepts insurance. I understand that I am responsible for payment of services rendered and I am also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.

Patient/Parent/Guardian Signatureplease type your name to agree to the terms
Today's DatePlease enter today's date