Patient Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
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)
Email:
Primary Phone: (10 digit number)
Secondary Phone: (10 digit number)
Name of school:
Grade:
Patient's Dentist:
Phone #: (10 digit number)
Please list any other family members we have treated:
Whom can we thank for this referral?
Name of person accompanying child to appointment:
Relationship:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Siblings
Name:
Birthdate:
Gender:
Male
Female
Name:
Birthdate:
Gender:
Male
Female
Name:
Birthdate:
Gender:
Male
Female
Name:
Birthdate:
Gender:
Male
Female
Guardian 1
First Name:
Middle Initial:
Last Name:
Birthdate:
Address: (please update if different)
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)
Relationship to Patient:
Mother
Father
Guardian
Grandparent
Other
Marital Status:
Married
Single
Widowed
Divorced
Separated
Social Security #:
Primary Phone: (10 digit number)
Secondary Phone: (10 digit number)
Email:
Employer:
Guardian 2
First Name:
Middle Initial:
Last Name:
Birthdate:
Address: (if different)
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)
Relationship to Patient:
Mother
Father
Guardian
Grandparent
Other
Marital Status:
Married
Single
Widowed
Divorced
Separated
Social Security #:
Primary Phone: (10 digit number)
Secondary Phone: (10 digit number)
Email:
Employer:
Person Responsible for Financials
Who is responsible for account:
Guardian 1
Guardian 2
Other
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)
Cell: (10 digit number)
Work:
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
Does the patient have any allergies or medical conditions?
No
Yes
If yes, please explain:
Dental History
Does the patient have any previous dental or oral issues?
No
Yes
If yes, please explain:
Do you have any specific concerns with the patient's 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.