New Patient Adult Form

Name

Date of Birth

Sex

How did you find us?

Address

Telephone #

Cell phone #

Email address

Referred by

Dentist

Physician

Orthodontic dental insurance

Yes
No

Social Security #

Name of dental insurance

Group/Policy #

Name of insured

ID #

Employed by

Occupation

Business address

Business telephone#

Spouse’s name

Employed by

Business address

Business telephone#

Occupation

MEDICAL HISTORY

Are you in good health?

Yes
No

Are you under the care of a physician for a major illness?

Yes
No

Explain

Do you have a latex allergy?

Yes
No

Explain

Check any of the following for which you have been treated:

Other

List any medications being taken now

Are you or do you suspect that you are pregnant:

Have you ever taken the following medication for Osteoporosis? Fosomax, Aotonel, Boniva, Aredia, Zometa:

DENTAL HISTORY

Have you had any injuries to your face, mouth or teeth?

Yes
No

Explain:

Do you have any pain or clicking of your jaw joints?

Yes
No

Explain

Do you clench/grlnd your teeth?

Yes
No

While asleep?

Yes
No

Are you a mouth breather?

Yes
No

While awake?

Yes
No

Have you been informed of any missing or extra teeth?

Yes
No

Do you have any crowns, bridges, or implants?

Yes
No

Have you ever had any periodontal (gum) problems ?

Yes
No

Have any of your children had orthodontic treatment?

Yes
No

What are your main concerns and your main reason for this examination/consultation?

Signature of patient

Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

I have been informed of your Notice of Privacy of Practice containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practice from time to time and that I may contact this organization at any time at the above address to obtain a current copy of the Notice of Privacy Practices I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Patient name

Signature

Relationship to patient

Date

CAPTCHA

New Adult Patient Form

MEDICAL HISTORY

DENTAL HISTORY

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE