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1 Patient Information
2 Employment
3 Insurance
5 Medical History
6 Conditions
Patient Information
Marital History
First Name
Last Name
Drivers License #your full name
Social Security Number
Birth Date
Spouse Name
Spouse SSN
Spouse Phone
Contact Information
Mailing Address
Zip Code
Home Phone
Cell Phoneyour full name
Emergency Contact
Who Should We Call in an Emergency?
Phone Number
Who Can We Thank for Referring You?
Patient Employment Information
Patient Employed By
Phoneyour full name
Employer Addressyour full name
Cityyour full name
Zip Code
Current Postion
How Long In Position
Spouse Employment Information
Spouse Employed By
Employer Addressyour full name
Zip Codeyour full name
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
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

**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
Dental History
Do You Have a Dental Exam on a Regular Basis?
Last Visitof appointment
Do Your Gums Bleed
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
Medical History
Do you presently have any conditions our staff should be aware of?
Please describe the conditions
0 /
Have you ever been hospitalized or had a major operation?
Please provide details of hospitalization or operation
0 /
Are you under a physician’s care now?
Please provide physicians name and additional information about treatment.
0 /
Have you ever had a serious injury to your head or neck?
Please provide information about the injury.
0 /
Are you taking any medication, pills or drugs?
Please provide information about the medication or drugs.
0 /
Are you on a special diet?
Please provide details about the diet.
0 /
Are you allergic to any medications or substances?
List Allergies
Please check any previous or current conditions:

Please contact our office prior to you appointment. Premedication may be required

Have you ever had any other serious illness not checked above?
Please describe the illness.
0 /
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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