Title

First Name*

Middle Name or Initial

Last Name*

Preferred Name

Gender*

Male Female

Marital Status

Height

Weight

Date of Birth*

Current Age*

Social Security number

Driver's License number

Address

Do you have a different billing address?

Yes No

Billing Address

Billing City

Billing State

Billing Zip

Contact Information

Home Phone*

Mobile Phone

Work Phone

Email*

Best time & number to contact you*

Emergency contact name and phone number*

Name of Referring Dentist

Insurance Information

By providing the information below, we can review your insurance plan before you arrive to maximize your benefits.

Employer of Insurance Holder

Employer Phone of Insurance Holder

Insurance Company

Insurance Company Phone

Policy number

Group number

Secondary Insurance

Employer of Secondary Insurance Holder

Employer Phone of Secondary Insurance Holder

Secondary Insurance Company

Secondary Insurance Company Phone

Secondary Policy number

Secondary Group number

Medical History

Name of Personal Physician & Office Address

Personal Physician Phone Number

Rate your overall health*

Excellent

Good

Fair

Poor

Our office offers Oral Conscious Sedation and IV Sedation services. Would you be interested in learning more about our Sedation Dentistry services?

Nitrous Conscious Sedation IV Sedation Not interested

Medical History - Women Only

Are you taking Birth Control or Hormones?

Yes No

Are you pregnant?

Yes No

If pregnant, what is your delivery date?

Possibly pregnant or trying to get pregnant?

Yes No

Are you nursing?

Yes No

Select the following drugs you have used at any time:*

Actonel

Aredia

Bisphosphonate

Boniva

Didronel

Fosamax

Skelid

Zometa

None of the Above

Signature of Patient (Responsible Party if a minor):*

Legal binding signature. Please type your full legal name.

Patient Information

Address

Billing Address

Contact Information

Insurance Information

Secondary Insurance

Medical History

Medical History - Women Only

Do you have or have you ever had any of the following