Complete Your New Patient Forms "*" indicates required fields Name* First Middle Last Address Street Address City State / Province / Region ZIP / Postal Code Telephone (Home)WorkCellEmail* Martial StatusSS#Date Of Birth MM slash DD slash YYYY Referring DentistPatient Employer and Address Street Address Dental Card Holder Information:NamePhoneWho to call in case of emergency:Name of InsuredEmployerInsurance Company NameAddress Street Address City State / Province / Region ZIP / Postal Code Date Of Birth MM slash DD slash YYYY SS#Responsible party if other than the patient above or patient is a minor:NameAddress Street Address City State / Province / Region ZIP / Postal Code Mother's SS#Father's SS#NamePhysicianCheck any of the following you have had or presently have or had Anxiety Asthma Cancer Claustrophobic Diabetes Excessive Bleeding Heart Murmur Hiatal Hernia High Blood Pressure HIV Positive Radiation Therapy Prosthetic Joints Stroke Ulcers Kidney, Liver or Lung Disease Gag Reflex Hepatitis A, B, or C Heart Trouble Osteoporosis Heart Palpitations Are you allergic or had an adverse reaction to: Codeine/Hydrocodone Keflex/Cephalexin Penicillin/Amoxicillin Erythromycin Doxycycline/Tetracycline Latex Aspirin/Ibuprofen/NSAIDS Other Allergies Other AllergiesAre you taking any medications?:Medication Add RemoveDosage Add RemoveReason For Taking Add RemoveHave you taken bisphosphonate( Actonel, Boniva, Fosamax, Fosamax D, Skelid, Didronel) orally or IV for any condition currently or in the past? If so, please explain?Are you under a physician’s care now? If so, for what?Have you ever been told to be pre-medicated for dental work?Females-Are you pregnant?What is your chief dental complaint? Sensitive? Hot? Is there swelling? Do you have biting & chewing painIs there any other medical or dental information that you feel | should know about?SignatureDate MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
