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
Top Related