Patient Information

Full Name

Date of Birth

Sex

Street Address

Apt / Unit

City

Postal Code

Home Phone

Business Phone

Cell Phone

Email

Occupation

Employer

Account Responsibility

Referred By

P.O.A. / S.D.M.

Contact #

Insurance Information

Insurance Company

Policy #

Policy Holder's Name

Policy Holder's Date of Birth

Relationship to Patient

Plan / Group #

I.D. #

* Add Co-Insurance information on a separate page if applicable.

Dental History

Previous Dental Provider

Dental Provider Phone

Last Visit Date

Last X-Ray Date

Visit Frequency

Biannual Annual Emergency Only Other:

Do you grind your teeth?

Yes No

Do your jaw joints pop or grind?

Yes No

Are your gums tender or sore?

Yes No

Have you had any injuries or surgeries to your mouth?

Yes No

Do you snore?

Yes No

Do you gasp or stop breathing in your sleep?

Yes No

Details / Additional Notes

Medical Information

Family Physician

Physician Phone

Are you currently under medical treatment?

Yes No

Reason (if yes)

Last Visit

Emergency Contact Name

Emergency Contact Number

Have You Ever Been Treated For Any of the Following?

Are you currently taking any medication for this condition or any other reason?

Yes No

Specify Rx / Supplements

Are you on antibiotics?

Yes No

Do you smoke?

Yes No

Other Medical Conditions

Have You Ever Had Any Major Operations or Illness?

Operation / Illness	Occurrence Date

Medical History Updates

Update / Specify	Date of Update

New Patient Form

Location

Contact Us

Business Hours

New Patient Form

Location

Contact Us

Business Hours

We Accept the CDCP Plan!