Patient Forms

Thank You!
Your registration has been sent to our office.

Name *

Patient's Birthday

SS#

Address

City

Zip

Home #

Cell #

Business #

E-mail

Marital Status

Spouse's Name (Parent or Guardian if Minor)

Employer

Other family members living at same address

Responsible Party

Emergency Contact

Telephone

Person Providing Insurance

Insured Birth date

Dental Insurance Company Name

Policy/Group #

Insured Employer's Name

Insured SS#

Insurance Co Address

Ins Co Phone #

As a courtesy to our patients, we are happy to submit all insurance claims at no charge. It is up to the patient to fully understand their insurance benefits and to be responsible for that portion of the account that the insurance does not pay.

What prompted you to see dental care at this time?

Reason for leaving former dentist

Referred By

How long since you have been to a Dentist?

Since had dental X-rays?

Previous Dentist name to call for X-rays?

Previous Dentist Phone #

Have you ever been treated for periodontal (gum) disease?

Yes

Do you grind or clench your teeth?

Yes

Are you in good health?

Yes

Are you presently under the care of a physician?

Yes

Explain

Are you taking any medications?

Yes

(i.e. Coumadin, Bloodthinners, Cortison, Insuline, Digitalis, Dilantin, Fosamax)

List

Have you had abnormal bleeding associated with previous extractions, surgery or trauma?

Yes

Do you have any prosthetic replacements?

Yes

(i.e Hip, Knee, Heart Valve)

Have you ever been required to take antibiotics prior to dental procedures?

Yes

Comments

Signature

Upon signing, I understand that I will be charged 1.5% per month (18% annually) on all unpaid balances 90 days past due.

Call Us: (954) 389-0511

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