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We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we’ll be glad to help you. We look forward to working with you in maintaining your dental health.
Date __________________________ Phone (_____) _________________________ Alt. Phone (_____) _______________________________ Name __________________________________________________________________ SS/HIC/Patient ID # ______________________________ Address ________________________________________________________________ E-mail ________________________________________ City __________________________________________________________________ State _________ Zip _____________________________ Sex □ M □ F Age_______ Birthdate ___________________________________ □ Married Information
□ Separated □ Divorced □ Partnered for ______ years Patient Employer/School __________________________________________________ Occupation ____________________________________ Employer/School Address _________________________________________________ Employer/School Phone (_____) ___________________ Patient Whom may we thank for referring you? ______________________________________
In case of emergency who should be notified? ________________________________ Phone (_____) __________________________________ Person Responsible for Account _____________________________________________________________________________________________ Relation to Patient _________________ Birthdate _____________________ Soc. Sec. # ____________________________________________ Address (If different from patient’s) ___________________________________ Phone (_____) _________________________________________ City ___________________________________________________________ State _________ Zip _____________________________________ Insurance Person Responsible Employed by ____________________________________ Occupation ____________________________________________
Business Address _________________________________________________ Business Phone (_____) __________________________________ Insurance Company _________________________________________________________________________________________________________ Primary Contract # _______________________ Group # ______________________ Subscriber # ___________________________________________
Names of other dependents covered under this plan _____________________________________________________________________________ Is patient covered by additional insurance? □ Yes □ No Subscriber Name __________________ Birthdate _____________________ Relation to Patient ______________________________________ Address (If different from patient’s) ___________________________________ Phone (_____) _________________________________________ City ___________________________________________________________ State _________ Zip _____________________________________ Subscriber Employed by ____________________________________________ Business Phone (_____) __________________________________ Insurance Company ______________________________________________ Soc. Sec. # ____________________________________________ Contract # _______________________ Group # ______________________ Subscriber # ___________________________________________ Additional Insurance Names of other dependents covered under this plan _____________________________________________________________________________
Rev. 3/2012
#21764 – Medical Arts Press 1-800-328-2179
Please Complete Both Sides
Reason for Today’s Visit ____________________________________ Date of last dental care _________________________________________ Former Dentist ___________________________________________ Date of last dental X-rays _______________________________________ Address ________________________________________________________________________________________________________________ Check ( ✓ ) if you have had problems with any of the following: How often do you floss? ____________________________________ How often do you brush? _______________________________________ Physician’s Name _________________________________________ Date of Last Visit ______________________________________________ Physician’s Name _________________________________________ Date of Last Visit ______________________________________________ Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. □ Yes □ No Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. □ Yes □ No Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Ionimin, Adipex, Fastin (brand Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). □ Yes □ No names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). □ Yes □ No Have you had any serious illnesses or operations? □ Yes □ No If yes, describe ________________________________________________ Have you had any serious illnesses or operations? □ Yes □ No If yes, describe ________________________________________________ Have you ever had a blood transfusion? □ Yes □ No If yes, give approximate dates ____________________________________ Have you ever had a blood transfusion? □ Yes □ No If yes, give approximate dates ____________________________________ (Women) Are you pregnant? □ Yes □ No Taking birth control pills? □ Yes □ No (Women) Are you pregnant? □ Yes □ No Taking birth control pills? □ Yes □ No Check ( ✓ ) if you have or have had any of the following: Check ( ✓ ) if you have or have had any of the following: MEDICATIONS: List medications you are currently taking: _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ I certify that I, and/or my dependent(s), have insurance coverage with _____________________________________________ and assign directly to Dr.___________________________________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative Authorization
Please print name of Patient, Parent, Guardian or Personal Representative Payment is due in full at time of treatment unless prior arrangements have been approved.

Source: http://images.quill.com/images/Products/catalog/Content/DataSheets/21764_Datasheet.pdf