Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Preferred Name:
Gender:
Main Phone:
Phone Type:
Address:
City:
State:
Zip:

Who may we thank for referring you to our office?
Have we treated any family members?

Confidential Responsible Party Information

First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Email:
Marital Status:
Main Phone:
Phone Type:
Address:
City:
State:
Zip:
How long at this address?
Social Security Number:
Birthdate:
Employer:
Occupation:
Length of Employment:
Spouse Name:
Cell Phone:

Dental Insurance Information

Policy Holder's Name:
Policy Holder's Birthdate:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Phone:
Policy Holder's Employer:

Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Policy Holder's Birthdate:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Phone:
Policy Holder's Employer:

Medical & Dental History

Do you have pain or clicking/popping noises in the jaw?
Are you aware of either clenching or grinding of teeth?
Do you have frequent headaches?
Do you have habits such as finger/thumb sucking or nail/lip biting?
Do you have speech problems, or are you in speech therapy?
Have you had your tonsils and/or adenoids removed?
Is there a tendency to faint or become dizzy?
Do you bleed easily?
Do you smoke or chew tobacco?
Do you have difficulty breathing through the nose?
Have there been any injuries to the teeth?
Do you have ear problems? (aches, ringing, dizziness, fullness)
Do you have sleep apnea?
Have you had any permanent teeth extracted?
Are you currently under any medical treatment?
Do you have a heart condition?
Do you pre-medicate?
Do you have a specific learning disability?
Do you have a behaviour disorder?

Please check all that apply:
Please list any medications you are taking:

Allergies or drug reactions to:
Please list any other allergies:

Dentist Name:
Phone:
Physician Name:
Phone: