Name:

Residence - Street:

Birthdate:

Soc. Security #Employer:

Occupation:

Refened by:

E Yellow Pages E lnsurance Co. Website or list

flCurrent Patient E Location fl lnternet Search flCIher

1ST COVERAGEWho is responsible for this account:Subscriber Name:

Subscriber Date of Birth:

Employer:

PERSONAL INFORMATIONHome Phone:Work Phone:

Cell Phone:

Where do you preferto receive calls:trHomeflWork trCellWren is the best time to reach you:

ln the event of an emergency, who should we call:Name:

Relationship:

Home Phone:

Work Phone:

CellPhone:

How do you wish to

E Single E Marriedbe addressed:

E Divorced n Widowed

City, State, Zip:

E-MailAddress: Time: Day:

I would like to receive newsletters and other communications via email E Yes E No

I would like to receive text message confirmation of appointments E Yes E No

Name ofGroup #:

Subscriber lD or Soc Sec #:

Reason for today's visit.

Former Dentist:

City/State:Date of last dental visit:

Date of last dental X-Rays:How often do you floss:How often do you brush:ls there a reason for changing from your former dentist

that you would like to share:

Are you currently experiencing any problems with past

dentalwork:Is there anything

about your smile:

you would like to change

INSURANCE INFORMATION2ND COVERAGE

Subscriber Name:

Subscriber Date of Birth:

Employer:Name of lnsurance Co:

Group #:

Subscriber lD or Soc Sec #:

DENTAL HISTORYPlace a mark on '!es" or "no" to indicate if you have anv of the followino

lnsurance Co:

Blisters on lips or mouth:E Yes E No broken fillings:

Bad Breath:

Bleeding Gums:

Buming sensation

on tongue:

Chew on one side:

Dry mouth:

Fingemail biting:

Food collection

EYes E No Lip orcheek biting: EYes E No

EYes E No Looseteeth or

EYes E No

EYes ENoEYes ENoEIYes E No

EYes E No

EYes E No

EYes E No

E Yes E No Sensitivity to heat E Yes E No

EYes EI No Sensitivityto sweets: EYes E No

Sensitivityto biting: EYes ENo

Mouth breathing:

EYes E No Mouth pain, brushing:

[]Yes E No Orthodontictreatment:

Are you wearing Pain around ear:

a partial orfull denture: E Yes E No Periodontal treafnent:

Clicking or popping jaw: E Yes E No Sensitivity to cold:

Betweenteeth: EYes ENo Soresorgrowth

Grindingteeth; EYes EINo inyourmouth:

Gums swollen ortender;EYes E No Areyou interested

EYes E No

Jaw pain or tendemess: E Yes E No in dental whitening: E Yes E No

DatePatient or Guardian's Signature