New Patient Form Step 1 of 5 - Patient/Insurance Information 20% Patient InformationFirst Name * Required First Last Name * Required Last Phone * RequiredEmail * Required SSN * RequiredAddress * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Sex * RequiredMaleFemaleMarital Status * RequiredSingleMarriedWidowedSeparatedDivorcedBirthdate - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Patient EmployerOccupationWork PhoneHow would you like to be notified for upcoming appointments? Email Phone Text Mobile CarrierInsurance InformationAny Dental Insurance Coverage? * RequiredYesNoWho is your carrier? * RequiredID number/Social # * RequiredPerson Responsible for Account * RequiredRelation to PatientBirthdate - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY PhoneAddress (if different from patient's) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Patient Dental HistoryPlease 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?What is the name of your previous dental office?Reason for leaving your previous dental office? PermissionEmergency Contact * RequiredEmergency Contact Relation * RequiredEmergency Contact Phone * Required Patient Medical HistoryPhysician * RequiredLocation * RequiredDate of Last Exam - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Are you under medical treatment now? * RequiredYesNoHave you ever been hospitalized for any to any surgical operation or serious illness? * RequiredYesNoAre you taking any blood thinners or aspirin? * RequiredYesNoAre you taking any medication(s) including non-prescription medicine? * RequiredYesNoIf 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? * RequiredYesNoAre you nursing? * RequiredYesNoAre you taking birth control pills? * RequiredYesNoDo 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: AuthorizationConsent * 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.How did you hear about our office?Full Name * RequiredDate - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY
