New Patient Form

Patient Information:

First Name:___________________Last Name:___________________

Middle Initial:________

By what name do you wish to be called?___________________________

Street Address:___________________________________________

City & State:__________________Zip Code:________________

Home Phone:_________________Work Phone:_________________

Cell Phone:___________________E-mail:______________________

How do you prefer to be contacted?___________________________

Employer:____________________

Marital Status (circle):      Married     Single    Child    Other

Gender (circle):  Male    Female

Date of Birth:  Month________   Day______  Year__________

Responsible Party (circle):  Self  Other

    If Other, please specify: 

    Name:_____________________    Relationship:________________

How did you first learn about us?___________________________

Is there someone we may thank for referring you to us?___________

    If so, who?__________________

Is there anything you would like us to know about you so we can serve you better?

______________________________________________________

Insurance Information:

Primary Insurance:

Patient's Relationship to the Subscriber (circle):  Self   Spouse   Dependant   Other

Subscriber's Name:________________________________________

Primary Insurance #:____________

Group #:_____________________

Patient's Social Security #:___________________________

Subscriber's Social Security #:____________________________

Emergency Contact Information:

Contact Person:________________Relationship:__________________

Phone:______________________Other Phone:__________________

Medical History:

Primary Care Physician:_____________________________________

Phone:______________________

Allergy To:

(Circle all the following that apply)

Aspirin                   Barbituates                   Codeine                   Local Anesthetic

Penicillin               Sulfa                                 Iodine                      Latex

Other (specify):__________________________________________________

Conditions (past or present):

Anemia                                        Arthritis                                 Artificial Heart Valve         Asthma

Back Problems                          Bleeding Abnormally       Blood Disease                         Cancer

Chemical Dependency           Chemotherapy                    Circulatory Problems         Diabetes            

Congenital Heart Lesions     Cortisone Treatments       Frequent Coughing              Epilepsy

Fainting                                        Glaucoma                               Headaches                              Heart Problems

Heart Murmur                           Hemophilia                           Hepatitis                                  Hernia Repair

High Blood Pressure               HIV/AIDS                              Jaw Pain                                  Kidney Disease

Liver Disease                             Mitral Valve Prolapse       Osteoporosis                          Pacemaker

Radiation Treatment             Respiratory Disease           Rheumatic Fever                  Scarlet Fever

Shortness of Breath                Skin Rash                                Stroke                                       Tonsillitis

Swelling of Feet or Ankles    Thyroid Problems             Tobacco Habit                       Tuberculosis

Ulcer                                              Other (specify):_____________________________________

Medications:

List all medications you are currently taking:

Medication:                                 Dosage:                                        Purpose: 

____________________   ____________________   _____________

____________________   ____________________   _____________

____________________   ____________________   _____________

____________________   ____________________   _____________

____________________   ____________________   _____________

____________________   ____________________   _____________

If you have more, please continue the list on the last page.

Have you ever been told that you need pre-medication before certain dental

procedures?__________

Is there anything else you would like for us to know about your health?

_________________________________________________________

_________________________________________________________

Thank you.  We are looking forward to meeting you!