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Services
Cosmetic Dentistry
Preventative Dentistry
Restorative Dentistry
Oral Surgery & Prosthetics
Special Services
Orthodontic Treatment
Meet the Team
Patient Resources
Frequently Asked Questions
Online Patient Forms
About
About Us
Hancock Location
Contact
Services
Cosmetic Dentistry
Preventative Dentistry
Restorative Dentistry
Oral Surgery & Prosthetics
Special Services
Orthodontic Treatment
Meet the Team
Patient Resources
Frequently Asked Questions
Online Patient Forms
About
About Us
Hancock Location
Contact
Call for appointment
Annual Update Form
Annual Update Form
Step 1 of 5 - Patient/Insurance Information
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Patient Information
First Name
*
Required
First
Last Name
*
Required
Last
Phone
*
Required
Email
*
Required
Address
*
Required
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Sex
*
Required
Male
Female
Marital Status
*
Required
Single
Married
Widowed
Separated
Divorced
Birthdate
- must be mm/dd/yyyy format
*
Required
Date Format: MM slash DD slash YYYY
Patient Employer
Occupation
Work Phone
How would you like to be notified for upcoming appointments?
Email
Phone
Text
Mobile Carrier
Insurance Information
Any Dental Insurance Coverage?
*
Required
Yes
No
Who is your carrier?
*
Required
Person Responsible for Account
*
Required
Relation to Patient
Birthdate
- must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Phone
Address (if different from patient's)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Patient Dental History
Please check if you have had any of the following:
Bad breath
Bleeding gums
Clicking or popping jaw
Food collection between teeth
Grinding teeth
Loose teeth or broken fillings
Periodontal Treatment
Sensitivity to hot or cold
Sensitivity to sweets or biting
Sores or growths in your mouth
Frequent headaches
Orthodontic work
Prolonged bleeding following extractions
Pain (joint, ear, side of face)
Other
If other, please specify:
How many times per day do you brush?
How many times per day do you floss?
If you could change something about your smile or teeth, what would it be?
Permission
Emergency Contact
*
Required
Emergency Contact Relation
*
Required
Emergency Contact Phone
*
Required
Patient Medical History
Physician
*
Required
Location
*
Required
Date of Last Exam
- must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Are you under medical treatment now?
*
Required
Yes
No
Have you ever been hospitalized for any to any surgical operation or serious illness?
*
Required
Yes
No
Are you taking any blood thinners or aspirin?
*
Required
Yes
No
Are you taking any medication(s) including non-prescription medicine?
*
Required
Yes
No
If yes, what medications are you taking? (If you are not able to list them right away, please email/bring a list in.)
Do you currently use:
Alcohol
Tobacco
Coffee
Are you allergic to, or have had any reactions to any of the following:
Local Anesthetic (e.g. Novocain)
Aspirin
Codeine
Hay Fever
Latex
Penicillin or other Antibiotics
Other Allergies:
Are you, or think you might be pregnant?
*
Required
Yes
No
Are you nursing?
*
Required
Yes
No
Are you taking birth control pills?
*
Required
Yes
No
Do you have any of the following?
Anemia
Arthritis
Artificial Joints
Asthma
Cancer
Diabetes
Dizziness/Fainting
Epilepsy/Seizures
Glaucoma
Heart Condition
Heart Murmur
Heart Pacemaker
Hepatitis A, B, C
High/Low Blood Pressure
AIDS/HIV Infections
Jaundice
Kidney Condition
Radiation Therapy
Respiratory Problem
Rheumatic Fever
Sinus Trouble
STD
Stomach Problem
Stroke
Tumor/Ulcers
Other
If other, please list:
Authorization
Consent
*
Required
I agree to the below statement.
I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me
I authorize the use of the signature on all insurance submissions.
I understand this practice’s Notice of Privacy Practices written in plain language. This notice provides the usage of
Initial disclosure of my health information as protected by HIPAA.
I understand this office has the right to alter this privacy in regards to my health information. If changes occur this
Initial practice will provide me with a revised notice of the privacy policy upon my request.
I instruct the dentist and/or hygienist to deliver the care that, in their professional judgement, can best help me in the
Initial restoration of my health.
Full Name
*
Required
Date
- must be mm/dd/yyyy format
*
Required
Date Format: MM slash DD slash YYYY
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