Marital Status:

    Spouse's Name:

    Home Phone:

    Business Phone:

    Emergency Contact:

    Cell Phone:


    Social Security Number:

    Emergency Phone Number:

    Birth Date:




    Last Physical Date:

    Referred By:

    Previous Dentist:

    NOTE: These questions are for your benefit. This confidential information will assist us in your diagnosis and treatment.

    Check any of the following which apply to you

    Heart TroubleHeart SurgeryHeart Valve ProsthesesCongenital Heart ProblemsHeart MurmurRheumatic Fever/Scarlet FeverStrockHigh Blood PressureGlaucomaStomach Ulcers
    HemophiliaAnemiaLeukemiaSickle Cell DiseaseKidney DiseaseDiabetesThyroid DiseaseJaundiceLiver DiseaseHepatitis
    Hives/ShinglesSinus TroubleAsthmaEmphysemaTuberculosisPersistent CoughEpilepsyFainting/DizzinessHerpes/Cold SoresSexually Transmitted Disease
    AIDS/HIVJoint Replacement ProsthesisArthritisCancerChemotherapyCortisone MedicineBlood TransfusionPsychiatric CareDrug DependenceChild Births

    Please list all medications or drugs (inluding aspirin, vitamins, hormones, antacids, steroids or birth controll pills) which you are presently taking or have taken in the last siz months (including dose and frequency):

    Has there been any change in your general health in the last year?


    Have you been hospitalized, seiousely ill, injured ill, injured or under a doctor's care during the past two years?


    Are you allergic or have you experienced an unusual reaction to any drugs?

    Please List:

    Have you experienced excessive bleeding that required special treatment?


    Are you or have you ever been addicted to any medications?

    Please list:

    Is there a history of Diabetes in you immediate family?

    Heart Disease?

    Periodontal Disease?

    Have you ever been treated for a growth or tumor in any part of you body?


    Do you smoke cigarettes?



    How many per day?

    For how long?

    Do you have frequent headaches?


    Wake up with headaches?


    Have you ever had Botox or dermal fillers?

    Please list any disease, condition or problem (not listed) that you feel we should know about:

    WOMEN: are you pregnant or nursing?

    Anticipating Pregnancy?

    Experiencing meopausal symptoms?

    Dental Health History

    Check any of the following which you may have had or experienced:

    Injury to Face or JawSlow Healing Mouth SoresFever BlistersMouth UlcersSwollen GumsBleeding Gums
    Sensitivity to HotSensitivity to ColdMouth OdorBad Taste in MouthLoose TeethChange in Bite
    Aches in Jaw JointsTired Jaw or Sore MusclesClicking/Popping in JawJaw Locking-open/closedRoot Canal TherapyOrthodontic Therapy

    If you are currently experiencing pain in your mouth, where is it located?

    How do you feel about keeping your teeth for the rest of your life?

    Are you happy with the appearance of your teeth?

    If not, what would you change?

    Have you had previous periodontal (gum) treatment?

    If so, when?

    Have you had oral surgery?

    If so, what type and when?

    Have you had crown and/or bridgework?

    If so, when?

    Have you ever had orthodontic therapy (braces)?

    Have you ever worn a bite guard, bite plane or night guard?

    Have you notice any change in the position of your teeth?


    Do you have any difficulty chewing?


    Is it difficult to open your mouth wide?


    Are you worried about receiving dental treatment?

    If so, what is your main concern?

    When was your last dental treatment?

    For what?

    Previous Dentist:

    For how long?

    Last Cleaning:

    Last X-Rays:

    Pattern of Dental Care:


    Other concerns:

    Insurance Information

    Today's Date:

    Patient Name:




    What your prefer to be called?


    Birth Date



    Mailing Address:




    Home Phone

    Work Phone

    Cell Phone

    Referred By:


    Employer Address:



    Spouse's Name:

    Personal Responsible for the Account



    Blilling Address:




    Work Phone:

    Insurance Information

    Company Name:


    Insured SS#:

    Insured Name:

    Relation to patient:

    Insured Employer:

    Date of Birth:

    Emergency Contact:


    Financial Agreement

    Thank you for choosing our office. We are comitted to providing you with the best possible care. If you have any questions regarding fees for treatments, please feel free to discuss them with us. We will make every effort to avoid misunderstandings and preserve our relatioship.

    Payment for services is due at the time treatment is rendered. If you have dental insurance, we are anxious to help you receive maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our payment policies. We will be happy to process your insurance claims for reimbursement as well as accept insurance assignment from insurances we are participating providess with. Our office is provided with :general benefit" information from your insurance, which is not specific or a guarantee exact amounts to be paid by your insurance carrier. If there is any remaining balance after your insurance has processed your claim, the balance is your responsibility.

    Missed and broken appointments waste valuable manpower and raise fees for everyone. In an effort to reduce this expensive waste there will be a charge of $75.00 for broken or missed appointments. A broken appointment is classified as the failure to appear for an appointment, cancellation not made 48 hours in advance or lateness that results in an inability to complete scheduled treatment.

    Returned checks due to insufficient funds or closed accounts will have a $35 charge.

    If your account must be placed in the hands of a third party for collections, your account will be charged 1/3 of the total balance for collection fee.

    If you have any questions about the above information or any uncertainty regarding your insurance coverage, please do not hesitate to ask us.


    I read the above conditions of treatment and payment and agree to their content.

    Signature if guarantor of payment/responsible party:



    Relationship to Patient:

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