New Patient Form | Haines Family Dental

Background

Insurance

Medical History

Dental History

ABOUT YOU

Today's Date

Email Address

Social Security Number

Last Name

First Name

Mrs

I prefer to be called

Male

Female

Birthdate

Age

Home Address

Home Phone

Cell Phone

Who may we thank for referring you?

Other family member seen by us:

Other Dentist:

Present

Last Visit Date

INSURANCE - PRIMARY

Dental Coverage?

Yes

Insurance Company Name

Insurance Company Address

Insurance Company Phone Number

Group Number (Plan, Local or Policy Number)

Insured's Name

Relation

Insured's Birthdate

Insured's ID Number

Employer Name

INSURANCE -- SECONDARY

Dental Coverage?

Yes

Insurance Company Name

Insurance Company Address

Insurance Company Phone Number

Group Number (Plan, Local or Policy Number)

Insured's Name

Relation

Insured's Birthdate

Insured's ID Number

Emergency Contact

His/Her Name

Relation

Phone Number

MEDICAL HISTORY

Do you have a personal physician?

Yes

Physician's Name

Phone Number

Date of last visit

Are you currently under the care of a physician?

Yes

Please explain:

Your current physical health

Good

Fair

Poor

Do you smoke or use tobacco in any other form?

Yes

Have you had any metal rods, pins or implants?

Yes

Are you taking any prescription/over-the-counter or herbal supplemental drugs?

Yes

Please list each one:

Have you ever taken Fosamax, or any other bisphosphonate?

Yes

Have you been told that you snore or hold your breath while sleeping or wake up gasping for breath?

Yes

FOR WOMEN: Are you using a prescribed method of birth control?

Yes

Are you pregnant?

Yes

Week #:

Are you nursing?

Yes

Have you ever had any of the following diseases or medical problems:

Abnormal Bleeding

Herpes / Fever Blisters

Alcohol / Drug Abuse

High Blood Pressure

Anemia

HIV + / AIDS

Arthritis

Hospitalized for Any Reason

Artificial Bones / Joints / Valves

Kidney Problems

Asthma

Liver Disease

Blood Transfusion

Low Blood Pressure

Cancer / Chemotherapy

Lupus

Colitis

Mitral Valve Prolapse

Congenital Heart Defect

Osteoporosis / Paget's Disease

Diabetes

Pacemaker

Difficulty Breathing

Psychiatric Treatment

Emphysema

Radiation Treatment

Epilepsy

Rheumatic / Scarlet Fever

Fainting Spells

Seizures

Frequent Headaches

Shingles

Glaucoma

Sickle Cell Disease / Traits

Hay Fever

Sinus Problems

Heart Attack

Stroke

Heart Murmur

Thyroid Problems

Heart Surgery

Tuberculosis (TB)

Hemophilia

Ulcers

Hepatitis

Venereal Disease

Please list any other serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

Aspirin

Latex

Codeine

Penicillin

Dental Anesthetics

Tetracycline

Erythromycin

Other

Please list any other drugs / materials that you allergic to:

DENTAL HISTORY

Why have you come to the dentist today?

Do you require antibiotics before dental treatment?

Yes

Are you currently in pain?

Yes

Have you ever had a serious / difficult problem associated with any previous dental work?

Yes

Do you have fears about going to the dentist?

Yes

Have you ever had gum treatment?

Yes

Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?

Yes

Your current dental health is

Good

Fair

Poor

Do you like your smile?

Yes

Do your gums ever bleed?

Yes

How many times a week do you floss?

How many times a day do you brush?

What type of bristles?

Soft

Medium

Hard

How long do you use a toothbrush before replacing it?

Are your teeth sensitive to heat, cold, or anything else?

Have you lost any teeth?

Yes

If yes, why?

I have received a copy of this office's Notice of Privacy Practices

Yes

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I have received a copy of this office's Notice of Privacy Practices.

Date

Payment is due in full at the time of treatment unless prior arrangements have been approved.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly lo the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

Date