First:
Last:
MI:
Birthday:
SS#:
Email Address:
Home Phone:
Cell Phone:
Preferred Contact Method:
Gender:
Status:
Home Address:
City:
State:
Zip:
Does your whole family live at this address?
Emergency Contact Name:
Emergency Contact Phone:
Relationship:
Subscribers Name:
Subscriber ID#:
Relationship to Subscriber:
Insurance Company Name:
Insurance Phone Number:
Employer Name:
Group Name:
Group #:
Subscriber Name:
Employer:
Insurance Comments:
Name:
List all medications that you are now taking:
Anesthetic
Aspirin
Codeine
Ibuprofen
Iodine
Latex
Penicillin
Sulfa
Other:
Asthma
Bleeding Problems
Cancer
Diabetes
Heart Murmur
Heart Trouble
High Blood Pressure
Joint Replacement
Kidney Disease
Liver Disease
Psychiatric Treatment
Sinus Trouble
Stroke
Ulcers
Rheumatic Fever
What kind and how:
Full or Part Time?
Reason for your visit:
Date of last cleaning and exam:
Are You Pregnant?
Unusual reaction to dental injections?
Are you in pain?
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
Do you have BiteWing x-rays that are less than 1 year old?
I authorize this office to release information regarding my treatment to my dental insurance carriers. All insurance benefits are assigned to this office. I accept full responsibility for all charges related to my dental care.
How did you hear about us? If it was from a friend, please let us know so we can thank them!
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