The purpose of this form is to save you time on the day of your appointment. 

Please print it, then fill it in and bring to your first appointment. 

Patient Information:

First Name: _________________________________________

Last Name: _________________________________________

Middle Initial: ________

By what name do you wish to be addressed? __________________________

Street Address: __________________________________________________________

City & State: __________________________________________

Zip Code: __________________

Home Phone: ________________________

Work Phone: ________________________

Cell Phone: __________________________

E-mail: _________________________________________

How do you prefer to be contacted? ________________________________________________

Employer: ________________________________________________________________________

Marital Status (circle):  Married     Single     Child     Other

Gender (circle):  Male     Female

Date of Birth:  Month ________________  Day _______  Year _________   

Responsible Party (circle):  Self    Other   

         If Other, please specify:  Name: ________________________________________________

                                                Relationship: ___________________________________________

How did you first learn about us? _____________________________________________________

Is there someone we may thank for referring you to us? ___________

        If so, who? _____________________________________________________________________

Is there anything you would like us to know about you so we can serve you better? _____________

______________________________________________________________________________________

Insurance Information (if applicable):

Primary Insurance:

         Patient's Relationship to the Subscriber (circle):    Self     Spouse     Dependant      Other

         Subscriber's Name:  _____________________________________________

         Primary Insurance #: _______________________________________

         Group Number: ________________________________________

         Patient's Social Security #: __________________________________

Secondary Insurance:

         Patient's Relationship to the Subscriber (circle):     Self     Spouse      Dependant     Other

         Subscriber's Name:  _____________________________________________

         Primary Insurance #: _______________________________________

         Group Number: ________________________________________

Emergency Contact Information:

Contact Person: _______________________________________________

Relationship: ________________________________________________

Phone: _________________________________

Other Phone: _____________________________

Medical History:

Primary Care Physician: _____________________________________________

Phone: ________________________

Circle all the following that apply:

Allergy to:

Aspirin	Barbituates	Codeine
Local Anesthetic	Penicillin	Sulfa
Iodine	Latex	Other (specify): ________________________

Conditions (past or present):

Anemia	Epilepsy	Osteoporosis
Arthritis	Fainting	Pacemaker
Artificial Heart Valve	Glaucoma	Radiation Treatment
Asthma	Headaches	Respiratory Disease
Back Problems	Heart Problems	Rheumatic Fever
Bleeding Abnormally	Heart Murmur	Scarlet Fever
Blood Disease	Hemophilia	Shortness of Breath
Cancer	Hepatitis	Skin Rash
Chemical Dependency	Hernia Repair	Stroke
Chemotherapy	High Blood Pressure	Swelling of Feet or Ankles
Circulatory Problems	HIV / AIDS	Thyroid Problems
Congenital Heart Lesions	Jaw Pain	Tobacco Habit
Cortisone Treatments	Kidney Disease	Tonsillitis
Frequent Coughing	Liver Disease	Tuberculosis
Diabetes	Mitral Valve Prolapse	Ulcer

List all medications you are currently taking:

Medication	Dosage	Purpose

Have you ever been told that you need pre-medication before certain dental

procedures? ________________

Is there anything else you would like for us to know about your health?

_______________________________________________________________________

_____________________________________________________

Thank you.  We are looking forward to meeting you!