Patient info: MrMrsMiss

Patient Name:

Social Security Number :

Date of Birth:

Status:  ChildSingleMarriedOther

Address:

State: , Zip Code:

Home #: 

Work:

Cell #:

Emergency Contact:

Relationship: , Phone#:

Patient Employer or School :

Occupation:

Drivers License:

Email:

How did you hear about us? Refereed By:

Source: NewspaperRadioDrove byOther

Dental  History

Have you been having any specific problem? YesNo

Describe :

Date of last Dentist Visit:

Purpose:

Last Date of Visit:

Date of Last Exams:

Has Fear of discomfort kept you from regular visit: YesNo

How is your dental health? YesNo

Do you feel you have decay? YesNo

Gum Disease: YesNo

Are your gums sensitive & bleed easily?  YesNo

From your past leaning visits, what would you say your personal preference is? GentleMediumThorough

How many times a day do you brush?

How often do you floss?

Do you use a waterPik? YesNo

How do you feel about your smile? GoodFairPoor

What would you like to change about it? YesNo

PRIMARY ISURANCE INFORMATION / RESPONSIBLE PARTY

Relation to patient SelfSpouseParentsOther

Name of Policy Holder:

Social Security #:

Date of Birth:

Address:

State: , Zip Code:

House:

Work:

Cell:

Emergency Contact:

Relationship: 

Phone:

Patient Employer or School: [ text-PatientEmployerorSchool]

Occupation:

Insurance Company:

Group:

ID#:

Insurance Phone:

Insurance Address: