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Patient Information
Patient Name  ___________________________________
If a child, parent's name  ___________________________
Marital Status of Patient: (please circle)
Married,  Divorced,  Single.  Separated,  Widowed
Patient's Date of Birth________________ Age _________
Patient's SS# ___________________________________
Address / Street _________________________________
City _____________________ State_____ Zip_________
Home Phone # __________________________________
Cel Phone # ____________________________________
Business Phone # _______________________________
Email _________________________________________
Employer ______________________________________
Whom may we thank for referring you to our office?
______________________________________________
In case of an emergency, who should be notified?
Name  _________________________________________
Relationship to patient ____________________________
Phone number __________________________________

Dental Insurance
Primary Dental Insurance
Insurance Co Name ______________________________
Insurance Address _______________________________
_______________________________________________
Insurance Phone # _______________________________
Name of Insured _________________________________
Insured's Birthday ________________________________
Insured's Social Security # _________________________
Insured's ID # ___________________________________
Group Number __________________________________
​Insured's Employer _______________________________

Secondary Dental Insurance
Insurance Co Name ______________________________
Insurance Address _______________________________
Insurance Phone # _______________________________
Name of Insured ____________________DOB_________
Insured's Social Security # _________________________
Dental Information
Have you ever been told that you meed an antibiotic before dental treatment?   Y / N
If so, for what? ____________________________________
When was your last visit? ___________________________
________________________________________________
Are you having dental discomfort at this time? ----- Y / N
Do you have pain in your jaw or near your ears? -- Y / N
Do you have unhealed injuries or inflamed areas in or around your mouth?  ------------------------------------------------ Y / N
Any reaction or allergic symptoms to Novocain, local or general anesthetic? -------------------------------------------------- 
Y / N
Any difficult extractions in the past? ------------------ Y / N
​Any prolonged bleeding following extraction in
the past? ----------------------------------------------------- 
Y / N
Do your gums bleed? ------------------------------------- Y / N
Do you have a bad taste in your mouth or
mouth odor? ------------------------------------------------- Y / N
Have you ever had Periodontal Treatment? --------- Y / N
Do you 
habitually clench or grind your teeth during the day or night? ---------------------------------------------------------- Y / N
Are any parts of your mouth sensitive to Hot, Cold
or Sweets? --------------------------------------------------- Y / N
Do you have dental implants? -------------------------- Y / N

Is there anything about the appearance of your teeth that you would like to change? ------------------------------------- Y / N
If so, what? ______________________________________
​
​Medical Care

Do you have a personal physician? -------------------  Y / N
Physician's name _________________________________
Are you presently under your physician's care? ---- Y / N
If so, for what? ___________________________________
Are you taking any medications? ----------------------- Y / N
Please list: ______________________________________
_______________________________________________
_______________________________________________


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