Patient Name________________________________________________________ Preferred Name:___________________ Birth Date_____________ Age: ______ SS#: __________________ Single ( ) Address ______________________________________ City/State/ Zip ____________________________ Home #:___________________ Cell #: ____________________ Which number do you prefer for us to contact you with? ________________ Email_____________________________________ Whom may we that for referring you? _____________________________ Other family members seen by us:________________________________ Previous/Present Dentist: _________________________ (Please circle) Do you have insurance? Yes No Insured's Name: ____________________________ Insured’s Birthdate: _________________ Insurance Co. Name: ________________________ Insurance Co. Phone #: __________________________ Insured’s SS # or ID#: _______________________ Insured’s Employer:_____________________________ Insured's Name: ____________________________ Insurance Co. Name: ________________________ Insurance Co. Phone #: __________________________ Insured’s SS # or ID#: _______________________ Insured’s Employer:____ ________________________ We gladly process your insurance claims on your behalf. Please note that your insurance policy is a contract between you and your insurance carrier. We are an out of network PPO provider. In the event of an emergency, Please provide a contact: Name __________________ Phone #: ______________ Relation:___________________ DENTAL HISTORY
Check (√ ) if you have had a problem with any of the following:  Bad Breath How often do you floss?______________________ How often do you brush?_______________________ MEDICAL HISTORY
Physician’s Name _______________________________________________ Date of Last Visit______________
Have you had any serious illnesses or operations? _________ If yes, describe_____________________________
(Women) Are you pregnant? Yes  No Nursing? Yes  No
Taking birth control pills? Yes  No Check (√ ) if you have or have had any of the following:  Arthritis, Rheumatism  Cough, Persistent  Artificial Heart Valves  Cough up blood  Chemical Dependency  Heart Problem Have you ever taken any of these medications? Diet Medications:
Blood Thinners:

Do you require antibiotics before dental treatment? Yes No

List medications you are currently taking______________________ _______________________________________________________  Barbiturates (Sleeping Pills)  Sulfa _______________________________________________________ Pharmacy Name _____________________ Phone_______________ SIGNATURE
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. ______________________________________________________________ Signature of Patient, Parent, Guardian or Personal Representative _____________________________________________________________________ Please print name of Patient, Parent, Guardian or Personal Representative Patient Name: ___________________________________
Please circle the letter of the response that is closest to yours:
My mouth is:
A. Follow the dentist’s recommendations C. Rarely go and don’t care about dentistry
I put dentistry:
B. Want to keep my teeth but have a limited budget C. Believe losing my teeth is part of aging A. Very satisfied with the appearance of my mouth B. Somewhat satisfied with the appearance of my mouth C. Dissatisfied with the appearance of my mouth
My present state of dental health is:

Thank you for filling out these forms completely. It will enable us to help you more effectively. If you have any
questions at any time, please ask us. We are happy to help.

We want our office to have a friendly and personable atmosphere. We will work together as a team to offer our patients the latest techniques in dentistry. Our office constantly takes continuing education courses which enable us to perform the dentistry with the highest standards possible. We have committed ourselves to the total well being of our patients. We will be compassionate and understanding of their dental concerns. We value each and every person in our practice. We strive for constant improvement and excellence. We will develop in our patients a confidence and a feeling of accomplishment.

Source: http://haroldkrinskydds.com/wp-content/uploads/2013/pdfs/New-Patient-Form.pdf

Microsoft word - guidelines for applicantsjuly2010final

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