Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Gender:
Today's Date:
Birthdate:
Cell Phone:
Email:
Home Address:
City:
State:
Zip:
Other family members seen by us:
Dentist Name:
Phone:
City:
Last Dental Visit:
Whom may we thank for referring you to our practice?

Parent/Guardian/Responsible Financial Party Information

Who will be financially responsible for treatment?

Primary Responsible Party

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Cell Phone:
Email:
Relationship to Patient:

Secondary Responsible Party

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Cell Phone:
Email:
Relationship to Patient:
Marital Status:
If separated or divorced, would you like our office to create two separate financial accounts for your child's treatment?

Dental Insurance Information

Do you have dental insurance?
How long have you had this insurance?
Insurance Company Name:
Insurance ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Subscriber's Name:
Subscriber's Birthdate:
Relationship to Patient:

Emergency Contact Information

Name of person to contact in case of an emergency:
Relationship to Patient:
Phone:

Medical and Dental History

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart murmur?
Bleeding problems of any kind?
Premedicate before dental visit?
Hemophilia?
Heart disease or heart attack or stroke?
Diabetes?
Hepatitis?
Rheumatic fever?
HIV or AIDS?
Asthma?
Speech problems?
Convulsions/Epilepsy?
Apprehensive about dental care?
Fibromyalgia:
Any missing or extra permanent teeth?
Any recent hospital stays?
Grind or clench teeth?
Sleep apnea or snoring issues?
Currently taking any medications?
Jaw joint (TMJ) pain, clicking or popping?
History of Cancer and Cancer treatment ?
Injuries to face, head, or jaw?
Allergies (Nickel, Latex, Penicillin, Sulfa, Other)?
Oral habits (Nail-biting, thumb or lip sucking, chewing ice or pens)?
Bone disorders or loss?
Covid in the last 2 months?
If yes to any of above, please explain:
Please list any medications you are currently taking:
Do you have arthritis or joint problems?
Have you taken any type of osteoporosis medicine:
Has there ever been a time when your jaws did not open or close?
Do you have a history of periodontitis?
Do you smoke: If so, how often:
Do you have any problem chewing, talking or swallowing?
How often do you have headaches:
How often do you take pain medication:
Have you previously had orthodontic treatment? If yes, when did you finish treatment?
What concerns do you or your doctor have about your smile or teeth?

Thank you for taking the time to complete this online form. Please make sure to email us (info@SublimeSmiles.com) photos of the front and back of your dental insurance card, so that we can verify your eligibility and benefits before your consult

E-Signature:
Date: