Welcome to our Office!

To help us meet your healthcare needs, please fill out this form completely. All information submitted on this form is confidential.
If you have any questions or need assistance, please call our office at (386) 304-1181 and we will be happy to help.

Patient Information

First Name
Last Name
Gender	MaleFemale
Date of Birth
Social Security Number
Cell Phone Number
Home Phone Number
Address LIne 1
Address Line 2
City
State
Zip Code
Email Address
Driver's License Number
When confirming appointments how do you prefer to be contacted?	Phone Email Text Message
Patient or Parent's Employer
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship

Responsible Party

Is the patient responsible for this account? Yes No
Name of Person Responsible for this Account		Relationship to Patient
Contact Phone	Birth Date	Employer
Social Security Number		Work Phone
Is this Person Currently a Patient in our Office? Yes No
For your convenience we offer the following methods of payment. Please check the option you prefer. Cash Personal Check Visa/Mastercard Discover CareCredit®

How did you hear about our office? (Check All That Apply)

TV Google Website Print Ad Drive By Brochure
Friend
Patient

Insurance Information

Name of Insured Relationship to Patient
Birthdate Social Security Number
Name of Employer Date Employed Union or Local Number
Work Phone Insurance Company Group Number
Policy/ID # Ins. Co. Address

Medical Health History

Physician Office Phone Date of Last Exam
1. Are you under medical treatment now? Yes No
2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? Yes No If yes, please explain
3. Are you taking any medication(s) including non-prescription medicine? Yes No If yes, what medications are you taking?
4. Are you currently taking or have you ever taken osteoporosis medications in the past? Yes No If so, how long ago and for how long did you take them? Which medications?
5. Do you use Tobacco? Yes No 6. Do you use controlled substances or recreational drugs? Yes No
7. Are you allergic to:
Local Anesthetics (e.g. novocaine)		Yes No
Penicillin		Yes No
Other Antibiotics		Yes No	Which antibiotics?
Sulfa Drugs		Yes No
Sedatives		Yes No
Iodine		Yes No
Aspirin		Yes No
Ibuprofen		Yes No
Tylenol		Yes No
Codeine		Yes No
Any Metals (e.g. nickel, mercury, etc.)		Yes No
Latex Rubber		Yes No
Other		Yes No	Please list:
9. Do you have or have you had any of the following?
High Blood Pressure	Yes No	Hearing Impaired	Yes No	Sexually Transmitted Disease	Yes No
Heart Attack	Yes No	Heart Disease	Yes No	Stomach Troubles / Ulcers	Yes No
Rheumatic Fever	Yes No	Mitral Valve Prolapse	Yes No	Vertigo	Yes No
Swollen Ankles	Yes No	Congestive Heart Failure	Yes No	Neck Pain	Yes No
Fainting	Yes No	Cardiac Pacemaker	Yes No	Back Pain	Yes No
Seizures	Yes No	Heart Murmur	Yes No	Chest Pains	Yes No
Low Blood Pressure	Yes No	Frequently Tired	Yes No	Easily Winded	Yes No
Epilepsy / Convulsions	Yes No	Angina	Yes No	Stroke	Yes No
Cancer	Yes No	Anemia	Yes No	Hay Fever / Allergies	Yes No
Radiation Therapy	Yes No	Ephysema / COPD	Yes No	Glaucoma	Yes No
Diabetes	Yes No	Tuberculosis	Yes No	Recent Weight Loss	Yes No
Kidney Diseases	Yes No	Asthma	Yes No	Liver Disease	Yes No
AIDS or HIV infection	Yes No	Arthritis	Yes No
Thyroid Problem	Yes No	Joint Replacement or Implant	Yes No
Sight Impaired	Yes No	Hepatitis / Jaundice	Yes No
Other medical conditions

Patient Dental History

Name of Previous Dentist/Location Date of Last Exam/Cleaning
1. Do your gums bleed while brushing or flossing?	Yes No	8. Do you have frequent headaches?	Yes No
2. Are your teeth sensitive to hot or cold liquids/foods?	Yes No	9. Do you clench or grind your teeth?	Yes No
3. Are your teeth sensitive to sweet or sour liquids/foods?	Yes No	10. Do you bite your lips or cheeks frequently?	Yes No
4. Do you feel pain to any of your teeth?	Yes No	11.Have you ever had any difficult extractions in the past?	Yes No
5. Do you have any sores or lumps in or near your mouth?	Yes No	12.Have you ever had any prolonged bleeding following extractions?	Yes No
6. Have you had any head, neck or jaw injuries?	Yes No	13.Have you had any orthodontic treatment?	Yes No
7. Have you ever experienced any of the following problems in your jaw?		14.Do you wear dentures or partials? If yes, date of placement:	Yes No
Clicking	Yes No	15.Have you ever received oral hygiene instructions regarding the care of your teeth and gums?	Yes No
Pain (joint, ear, side of face)	Yes No	16. Do you like your smile?	Yes No
Difficulty in opening or closing	Yes No
Difficulty in chewing	Yes No

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand
that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records
of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I agree
to be responsible for payment of all service rendered on my behalf of my dependents.

Signature of Patient (parent of minor):

The signature box can be signed on touchscreen devices using a stylus or finger. With a mouse, simply left-click and and drag to write your signature. If you choose to leave the signature box blank, you will be asked to sign a printed copy of this form upon your first visit to our office.

Doctor's Signature:______________________________ Date:

Acknowledgement of Reciept of Notice of Privacy Practice

HIPAA

I hereby acknowlege that I have received and had an opportunity to ask questions concerning White Wolf Dental Group's Notice of PrivacyPractice.

Signature:

Patient's Name:	Date:
If signed by a representative, name of representative:
Relationship to Patient: