1 Contact Information
2 Insurance
3 HIPAA
4 Medical History
5 Conditions
Patient Information
Gender
First Name
Last Name
Social Security Number
School
Birth Date
date_range
Who should we contact in an emergency?
Mother's Information
Mother's Name
Mother's Birth Date
date_range
Mailing Address
City
State
Zip Code
Phone
Drivers Licenseyour full name
Social Security Number
Marital Status
Mother Employed By
Positionyour full name
Employer Address
Father's Information
Father's Name
Father's Birth Date
date_range
Mailing Addressyour full name
City
State
Zip Code
Phone
SSN
Drivers Licenseyour full name
Marital Status
Father Employed By
Positionyour full name
Employer Address
Insurance Information
Present your insurance card at the front desk when you arrive.
Insurance Provideryour full name
Insurance Provider Address
Policy #
Group #
Policy Holder's Name
Birthdateof appointment
date_range
Medicaid #
County
PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED. I understand that I am financially responsible for all charges on date of service whether or not paid by insurance. I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits.
Payment Not Covered by Insurance Will be Made With
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**You May Refuse to Sign This Acknowledgement**

Download, view or print this office's Notice of Privacy practices by clicking here. 

I have received a copy of this office’s Notice of Privacy Practices.

Full Nameyour full name
Dateof appointment
date_range
Dental History
Do You Have a Dental Exam on a Regular Basis?
Last Visitof appointment
date_range
Do Your Gums Bleed
Discuss
If you could change anything about your teeth or smile, what would you change?
0 /
What would you like your teeth to be like in 20 years?
0 /
Do you ever have clicking, popping or discomfort in the jaw joint? Do you brux or grind?
Have your past experiences in a dental office always been positive?
Do you smoke or chew, or have any sores or growths in your mouth?
Name of Previous Dentist
Date of last mouth x-rays
date_range
Medical History
Do you presently have any conditions our staff should be aware of?
Have you ever been hospitalized or had a major operation?
Are you under a physician’s care now?
Have you ever had a serious injury to your head or neck?
Are you taking any medication, pills or drugs?
Are you on a special diet?
Are you allergic to any medications or substances?
Conditions
Please check any previous or current conditions:
Have you ever had any other serious illness not checked above?
To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail.
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