• Patient information
  • Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. lf there have been any changes in your health, please tell us. If you have any questions, please don't hesitate to ask.
  • Patient name
  • Today's date
  • Date of birth
  • Age
  • Gender
  • How did you hear about us?
  • Personal Referral Doctor Referral Insurance Referral Facebook Google Other
  • Driver's license number
  • State
  • Home address
  • Phone
  • Cell Phone
  • Email address
  • Billing address (if different from above)
  • Employer/occupation
  • Business phone
  • Spouse's name
  • Spouse's phone
  • Emergency contact and phone (other than spouse)
  • Primary dental insurance
  • Group number
  • Secondary dental insurance
  • Group number
  • Subscriber's name
  • Subscriber's insurance number
  • Date of birth
  • Age
  • Sex
  • Name of your medical doctor
  • Date of last visit to medical doctor
  • Name of previous dentist
  • Date of last visit to dentist
  • Referred to us by
  • Dental Health History
    • Do you have or have you had any of the following?
      (check all the apply)
    • Apprehension about dental treatment
      Problems with previous dental treatment
      Gag easily
      Wear dentures
      Food catches between your teeth
      Difficulty chewing your food
      Chew on only one side of your mouth
      Avoid brushing any part of your mouth because of pain
      Gums bleed easily
      Gums bleed when flossing
      Gums feel swollen or tender
      Notice slow-healing sores in or around your mouth
      Feel twinges of pain when your teeth come into contact with:
    • Hot foods or liquids
      Cold foods or liquids
      Sour foods
      Sweet foods
    • Take fluoride supplements
      Feel dissatisfied with the appearance of your teeth?
      Want to save your teeth?
      Want complete dental care?
    • How often do you brush?
    • How often to you floss?
    • Your jaw makes noise so that it bothers you
    • Or others
    • Clench or grind your teeth frequently
      Jaws feel tired
      Jaw gets stuck so that you can't open freely
      Pain when you chew or open wide to take a bite
      Earaches or pain in front of your ears
      Jaw symptoms or headaches upon awaking in the morning
      Jaw pain or discomfort affecting your appetite, sleep, daily routine, or other activities
      Jaw pain or discomfort that is extremely frustrating or depressing
      Take medications for pain or discomfort (pain relievers, muscle relaxants, antidepressants)
      Temporomandibular (jaw) disorder (TMD)
      Pain in the face, cheek, jaws, joints, throat, or temples
      Unable to open your mouth as far as you want
      Aware of an uncomfortable bite
      Had a blow to the jaw (trauma)
      Habitually chew gum?
    • Smoke? Pipe? Other?
    • Use chewing tobacco?

  • Medical Health History
  • Do you have or have you had any of the following?
    (check all that apply)
    • Heart problems
      Chest pain
      Shortness of breath
      Blood pressure problem
      Heart murmur
      Heart valve problem
      Taking heart medication
      Rheumatic fever
      Artificial heart valve
      Blood problems
      Easy bruising
      Frequent nosebleed/abnormal bleeding
      Blood disease
      Ever require a blood transfusion?
      Allergy problems
      Hay fever
      Sinus problems
      Taking allergy medication
      Intestinal problems
      Weight gain or loss
      Special diet
      Kidney or bladder problems
      Fainting spells, seizures or epilepsy
      Frequent or severe headaches
      Thyroid problems
      Persistent cough or swollen glands
      Pre-medications required by physician
      Urinate more than six times a day
      Thirsty or mouth is dry much of the time
      Family history of diabetes
      Tuberculosis or other respiratory disease
      Bone or joint problems
      Back or neck pain
      Joint replacement (e.g. hip, pins, implants)
    • Drink alcohol or use recreational drugs?
    • lf so, how much?
    • Hepatitis,jaundice or liver trouble
      Herpes or other STD
      HIV positive/AIDS
      Do you wear contact lenses?
      Head injury
      Epilepsy or other neurologic disease
      History of alcohol or drug abuse
    • During the past 12 months, have you
      taken any of the following?
    • Antibiotics or sulfa drugs
      Anticoagulants (e.g. Coumadin)
      High blood pressure medicine
      Insulin, Tolbutamide or similar drug
      Digitalis or drugs for heart trouble
      Cortisone (steroids)
      Natural remedies
      Nonprescription drug/supplements
    • Other
    • Are you allergic or have you reacted
      adversely to any of the following?
    • Local anesthetics (Novocain)
      Penicillin or other antibiotics
      Sulfa drugs
      Barbiturates, sedatives or sleeping pills
      Aspirin, acetaminophen or ibuprofen
      Codeine, Demerol or other narcotics
      Latex or rubber dam
    • Other
    • What medications are you currently taking?
    • taking?
    • Women
    • Are you taking contraceptives or other hormones?
      Are you pregnant?
    • If so, expected delivery date
    • Are you nursing?
      Have you reached menopause?
      If so, do you have symptoms?
  • Other disease, condition or problem not listed above:
  • Patient signature/legally authorized representative and relations

  • Doctor signature______________________
  • Date
  • Date______________________



Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by usin one or more of the following respects:

  • To other health care providers (i.e., your generaldentist, oral surgeon, etc.) in connection with our rendering periodical treatment to you (i.e., to determine the results of restorations, surgery, orthodontic treatment, etc.);
  • To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payments, etc.)
  • To certifying, licensing and accrediting bodies (i.e., the American Board of Periodontology, state dental boards, etc.) in connection with obtaining certification, licensure oraccreditation;
  • Internally, to all staff members who have any role in your treatment;
  • To other patients and third parties who may see or over hear incidental disclosures about your treatment, scheduling, etc.;
  • To your family and close friends involved in your treatment; and/or,
  • We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:

  • Request restrictions on the use and disclosure of your protected health information;
  • Request confidential communication of your protected health information;
  • Inspect and obtain copies of your protected health information through asking us;
  • Amend or modify your protected health information in certain circumstances;
  • Receive an accounting of certain disclosures made by us or your protected health information; and,
  • You may, without risk of retaliation, file acomplaint as to any violation by us of your privacy rights to us (by submitting inquires to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must befiled within 180 days of the violation).

We have the following duties under the privacy rules:

  • By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
  • To abide by the terms of our Privacy Notice that is currently in effect;
  • To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all projected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.

Please notes that we are not-obligated to:

  • Honor any request by you to restrict the use or disclosure of your protected health information;
  • Amend your protected health information if, for example, it is accurate and complete; or
  • Provide an atmosphere that is totally free ofthe possibility that your protected health information may be incidentally overhead by other patients and third parties.

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask our Privacy Contact Person or direct your questions to this person at our office. Thank you.


I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice.

Patient Signature


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