Patient Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Marital Status:
Married
Single
Widowed
Divorced
Separated
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip: (5 digits)
Primary Phone: (10 digit number)
Secondary Phone: (10 digit number)
Email:
Social Security #:
Patient's Dentist:
Phone #: (10 digit number)
Please list the names of any friends or family currently in the practice:
Whom can we thank for this referral?
Spouse Information
Spouse's Name:
Birthdate:
Email:
Primary Phone: (10 digit number)
Secondary Phone: (10 digit number)
Work:
Employer:
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip: (5 digits)
Primary Phone: (10 digit number)
Secondary Phone: (10 digit number)
Work Phone: (10 digit number)
Email:
Social Security #:
Employer:
Primary Dental Insurance Information
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:
Relationship to Patient:
Group #:
Member ID# or SS#:
Secondary Dental Insurance Information
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:
Relationship to Patient:
Group #:
Member ID# or SS#:
Medical History
Do you have any allergies or medical conditions?
No
Yes
If yes, please explain:
Dental History
Do you have any previous dental or oral issues?
No
Yes
If yes, please explain:
Do you have any specific concerns with your teeth?
Emergency Information
Who should we contact in the event of an emergency?
Phone: (10 digit number)
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Spouse
Stepfather
Stepmother
Other
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.