• *Today's date
• *Email Address
• *Name
  Mr Mrs Ms Dr
• I prefer to be called
• *Sex
  Male Female
• *Birthdate (MM/DD/YYYY)
  / /
• *Age
• *Social Security Number
  - -
• *Home Address
• Apt #
• *City
• *State
  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• *Zip Code
• *Marital Status
  Single Married Divorced Widowed Separated
• Home Phone
  -
• Work Phone
  -
• *Cell #
  -
• We sometimes communicate via text messages to confirm appointments. Would you like to receive text messages from our office?
  Yes No
• Employer
• Employer's Address
• How long there?
• Occupation
• Other family members seen by us

• *His / Her name
• Employer
• *Work Phone
  -
• *Social Security Number
  - -
• *Birthdate (MM/DD/YYYY)
  / /
• *Person responsible for account
• *Work Phone
  -
• Home Phone
  -
• *Billing Address
• *Relation
• *Social Security Number
  - -
• *Employer

• *Do you have dental insurance?
  Yes No

Primary Dental Insurance

• Insurance Co. Name
• Insurance Co. Address
• Insurance Co. Phone#
  -
• Group# (Plan, Local or Policy#)
• Insured's Name
• Relation
• Insured's Birthdate (MM/DD/YYYY)
  / /
• Insured's SS#
  - -
• Insured's Employer
• Employer's Address

Secondary Dental Insurance

• Insurance Co. Name
• Insurance Co. Address
• Insurance Co. Phone#
  -
• Group# (Plan, Local or Policy#)
• Insured's Name
• Relation
• Insured's Birthdate (MM/DD/YYYY)
  / /
• Insured's SS#
  - -
• Insured's Employer
• Employer's Address

In the event of an emergency, is there someone who lives near you that we should contact?

• His/Her Name
• Relation
• Work Phone
  -
• Home Phone
  -

• Do you have a personal physician
  Yes No
• Physician's Name
• Work Phone#
  -
• Date of last visit
• Your current physical health is
  Good Fair Poor
• Are you currently under the care of a physician?
  Yes No
• Please explain
• Are you taking any prescription / over-the-counter drugs?
  Yes No
• Please list each one below
• Drug:
• Purpose:
• Drug:
• Purpose:
• Drug:
• Purpose:
• Do you smoke or use tobacco in any other form?
  Yes No

Have you ever had any of the following disease or medical problems?

• *Why have you come to the dentist today?
• Do you require antibiotics before dental treatment? Yes No
• Do you have any artificial joints? Yes No
• Are you currently in pain? Yes No
• Have you ever had serious/difficult problem associated with any previous dental work? Yes No
• Do you now or have you ever experienced pain/discomfort in your jaw joint(TMJ/TMD)? Yes No
• Your current dental health is? Good Fair Poor
• Do you like your smile? Yes No
• Do your gums beed? Yes No
• Are you taking any OSTEOPOROSIS medications including Fosomax or BISPHOSPHONATES? Yes No
• When was your last dental visit?
• When were x-rays last taken?
• Previous dentist's name and address?
• When was the last time your teeth were cleaned?

• (Reviewed by Doctor)
• (Date)
• (Additional Notes)