Confidential Patient Information

Last Name:
First Name:
M.I.:
Preferred Name:
Gender:
Pronouns:
Date of Birth:
Age:
Social Security #:
Marital Status:
Patient Address:
City:
State:
ZIP (Postal Code):
Driver's Lic. #:
Cell Phone:
Home Phone:
Work Phone:
Can we reach you at your work number?
Employer:
Occupation:
E-mail Address*:
*For confirmation of appointments and company information only. We take your privacy very seriously.
Other Family Members at FCDG:
Emergency Contact Person:
Relationship to Patient:
Home Phone:
Work Phone:

Person Responsible for the Account

Last Name:
First Name:
Relation to Patient:
Billing Address:
City:
State:
ZIP (Postal Code):
Social Security #:
D.O.B.
Home Phone:
Work Phone:

Insurance Information

Primary Dental Insurance:
Insurance Company:
Subscriber Name:
Subscriber D.O.B.
Insurance Co. Address:
Insurance Co. Phone #:
Subscriber's Employer:
Group #:
Subscriber ID #:
Patient's Relationship to Subscriber:
Secondary Dental Insurance (If Applicable):
Insurance Company:
Subscriber Name:
Subscriber D.O.B.
Insurance Co. Address:
Insurance Co. Phone #:
Subscriber's Employer:
Group #:
Subscriber ID #:
Patient's Relationship to Subscriber:
Medical Insurance:
Insurance Company:
Subscriber Name:
Subscriber D.O.B.
Insurance Co. Address:
Insurance Co. Phone #:

Authorization

To my knowledge, the above information is correct. I hereby consent to any examinations, x-rays, diagnostic procedures, tests and/or treatment the doctor may prescribe.
I authorize release of any information relating to claims and wish to assign benefits to First Choice Dental. I am responsible for any amount not covered by my insurance. I understand that payment is due in full at the time of treatment unless prior arrangements have been approved.

Cancellations & Missed Appointments:
Your appointment time has been reserved exclusively for you to see the dentist or hygienist. We ask that you give us at least 48 hours advance notice when cancelling your scheduled appointment so that we may offer the time to another patient.

Dental History

Former or Current Referring Dentist:
Telephone:
Address/ Clinic Location:
City:
State:
ZIP (Postal Code):
Check-up Frequency:
Date of Last Dental Visit:
What is your main dental or orthodontic concern?
Have you had previous orthodontic consults or treatment?
Are you comfortable going to the dentist?
Would you consider your diet high in sweets/sugars?
How many times per day do you brush?
How many times per day do you floss?
Is your drinking water source well water, city water, or bottled water?
List any sports, hobbies, or musical instruments played?
Have you experienced any of the following?
Injury to head or neck
Grind or clench teeth
Injury to face, jaw, teeth, or mouth
Pain, tenderness, or noise in either jaw
Discomfort from teeth or gums
Frequent headaches
Teeth sensitive to hot or cold
Neck/shoulder pain
Avoid chewing on one side
Splint Therapy
Oral surgery
Oral habits (thumb/finger/lip/nail biting)
Bleeding gums
Abnormal swallowing (tongue thrust)
Gum treatment
Speech problems/therapy
Fluoride treatments
Frequent sore throats
Mouth breathing
Frequent gum chewing
Patients Under 18 (only):
Please list the name and birthdate of any siblings:
School Name:
Grade:
Father/Guardian Name:
Mother/Guardian Name:
Has either biological parent ever had orthodontic treatment?
Has the patient grown in the past year or has their shoe size changed recently?
Would you prefer any potential treatment be discussed without your child present?

Medical History

Physician Name:
Telephone:
Physician Address/Clinic Location:
City:
State:
ZIP (Postal Code):
Have you experienced any of the following?
Allergies
Alzheimer's/Memory Loss
Anemia
Anxiety
Arthritis
Artificial Heart Valve(s)
Artificial Joints
Date:
Asthma
Autism
Bone Disorders/Bone Loss
Cancer
Family History of Cancer
Canker Sores
Cerebral Palsy
Chronic Ear Infections
Chronic Pain/RSD/Fibromyalgia
Cold Sores
Diabetes
Family History of Diabetes
Drug/Alcohol Abuse
Dry Mouth
Eating Disorders/Bulimia/Anorexia
Emotional/Psychiatric Care
Excessive Daytime Sleepiness
Gastrointestinal Disorder
Glaucoma
Growth Problems
Handicaps/Disabilities
Hay Fever
Hearing Loss/Impairment
Heart Arrhythmia
Heart Attack
Heart Defect/Heart Disease
Family History of Heart Disease
Heart Murmur
Hemophilia/Abnormal Bleeding
Hepatitis A B C D
HIV/AIDS
Hormone Therapy
HPV
Hyperactivity/ADHD
Hypertension/High Blood Pressure
Kidney Disease
Liver Disease
Low Blood Pressure
Medical Transplant
Migraines
Mitral Valve Prolapse
Muscular Dystrophy
Nervous Disorders
Osteoporosis
Pacemaker
Pneumonia
Prolonged Bleeding/Transfusion
Radiation/Chemotherapy
Respiratory Disease
Rheumatic Fever/Scarlet Fever
Seizures/Epilepsy/Fainting
Sexually Transmitted Disease
Shingles
Sinus Problems
Sleep Apnea
Smoking/Tobacco Use
Snoring
Stroke
Thyroid Problems
Trouble Falling/Staying Asleep
Trouble Swallowing/Gag Reflex
Tuberculosis/Lung Disease
Tumors
Please note any other medical conditions:
Please note all previous surgeries:
Do you need to pre-medicate/take an antibiotic prior to dental appointments?
Are there any medications you have been prescribed but are not taking?
Would you like to speak with the doctor privately about any health concerns?
Are you currently taking any blood thinners?
Are you currently on birth control?
Have you ever taken oral or I.V. Bisphosphonates?
Please list any medication(s) you are currently taking and why (including over-the-counter medicines):
Medication:
Reason:
Medication:
Reason:
Medication:
Reason:
Medication:
Reason:
Medication:
Reason:
Medication:
Reason:
If you are taking more medications than space allows, please bring a complete list of medications to your appointment.
Do you have any allergies?
Are you pregnant or suspect you might be pregnant?
Are you currently nursing?
To my knowledge, the above information is correct. If there are any changes in my medical history, I will inform the doctor.
This form was signed by:
First & Last Name:
Email Address: