New Patient Form

Name

SS # (optional on-line)

Address

Phone

Alt Phone

Sex

Male Female

Age

Birthdate

How did you find us?

Referral Internet Search Social Media Other

Emergency Contact

Emergency Phone

Emergency Email

Relation to Patient

Work / Occupation Area

Employer

Occupation

Work Phone

Business Address

Work Email

Does Primary Patient Have Insurance?

Yes No

Dental History

What would you like us to do today?

Are You In Discomfort

Yes No

Date of Last Exam

Date of Last X-Rays

Former Dentist

Former Dentist Phone

Former Dentist Address

Check Yes or No if you have had any problems with the following:

Bad Breath

Yes No

Food Collecting Between Teeth

Yes No

Periodontal Treatment

Yes No

Sensitivity to Sweets

Yes No

Bleeding Gums

Yes No

Grinding or Clenching Teeth

Yes No

Sensitivity to Cold

Yes No

Clicking or Popping Jaw

Yes No

Loose Teeth or Broken Fillings

Yes No

Sensitivity to Hot

Yes No

Sores or Growths in Mouth

Yes No

How Often do you Brush?

How Often do you Floss?

How do you feel about the appearance of your teeth?

Have you ever had any adverse drug reaction during or related to medical or dental treatments?

Yes No Other

What else do we need to know about you or this visit?

Patients Medical History

Physicians Name

Physicians Phone

Date of Last Visit

Have you had a serious operation or illness?

Yes No

Are you currently under a Physicians Care?

Yes No

Have you ever had a blood transfusion?

Yes No

Have you ever taken Fen-Phen/Redux?

Yes No

Women: Are you Pregnant?

Yes No

Women: Nursing?

Yes No

Women: Taking Birth Control Pills?

Yes No

Select all that you have been diagnosed with

List all Medications

List all Drug Allergies

AUTHORIZATION I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine the appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist and his staff. I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by the insurance.

We will have a copy for you to sign when you arrive for your appointment.

PAYMENT IS DUE IN FULL AT THE TIME OF TREATMENT, UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED

Work / Occupation Area

Dental History

Check Yes or No if you have had any problems with the following:

Patients Medical History

Select all that you have been diagnosed with

About Saint Apollonia Dental

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