Graywhiteandallendental.com

WELCOME TO OUR PRACTICE
Date: _______________________

Patient Information

Name: _____________________________________________
Birthdate: ___________________
Social Security Number: ________________________
Address: _______________________________________
City: ____________________
State/Zip: __________________
Home Phone: ___________________________
Work Phone: _________________________
Cel Phone: _________________________
Check Appropriately: Minor ______ Single ______Married______ Divorced______ Widowed______
If Student, Name of School/College: __________________________________State: ____ Full Time/Part Time: ________
Patient or Parent’s Employer: _________________________________________ Phone: ___________________
Emergency contact: Name: ___________________________________ Phone: ___________________
Responsible Party

Name of Person Responsible for this Account: ________________________________
Relationship to Patient: ______________________
Address: ___________________________________ City: _________________ State/Zip: ____________
Best phone number: ___________________________ Insurance Information
Name of Insured: ___________________________________________ Relationship to Patient: ________________
Birthdate: _______________________ SS#: ____________________________
Name of Employer: _______________________________________________ Work phone: ____________________
Insurance Company: _______________________________________ Group #: _____________________
Insurance Company Address: ___________________________________ City: _________________ State/Zip: _____________
Patient Medical History
Physician: ___________________________________ Office Phone: ___________________ Date of last exam: ________
1. Are you under medical treatment now? 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 medication(s) are you taking? __________________________________________________________________ 4. Have you ever taken Fen-Phen/Redux? Yes____ No____ 5. Have you ever taken Fosamax, Boniva, Actonel or any caner medications containing bisphosphonates? Yes____ No____ 6. Have you taken Viagra, Revati, Cialis or Levitra in the last 24 hours? Yes____ No____ 7. Do you use tobacco? Yes____ No____ 8. Do you use controlled substances? Yes____ No____ 9. Are you wearing contact lenses? Yes____ No____ 10. Do you have persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)? Yes____ No____ 11. Women only: a. Are you pregnant or think you may be pregnant? Yes____ No____ b. Are you nursing? Yes____ No____ c. Are you taking oral contraceptives? Yes____ No____ 12. Are you allergic to or have you had any reactions to the following? : Local Anesthetics (e.g. Novocain) Yes____ No____ Penicillin or any other Antibiotics Any Metals (e.g. nickel, mercury, etc.) Yes____ No____ Latex Rubber Yes____ No____ Other (please list): _______________________________________________________________ 13. Do you have or have you had any of the following? Yes___ No___ Hay Fever/Al ergies Yes___ No___ Yes___ No___ Respiratory Problems Yes___ No___ Yes___ No___ Sexually Transmitted Disease Yes___ No___ Mitral Valve Prolapse Yes___ No___
Patient Dental History
Name of previous Dentist and Location: ________________________________________ Date of Last Exam: ________________
1. Do you gums bleed while brushing of flossing?
2. Are you teeth sensitive to hot or cold liquids/foods? 3. Are your teeth sensitive to sweet or sour liquids/foods? 4. Do you feel pain to any of your teeth? 5. Do you have any sores or lumps in or near your mouth? 6. Have you had any head, neck or jaw injuries? 7. Have you ever experienced any of the following problems in your jaw? : 10. Do you bite your lips or cheeks frequently? 11. Have you ever had any difficult extractions in the past? 12. Have you ever had any prolonged bleeding following extractions? 13. Have you had any orthodontic treatment? If yes, date of placement______________________________ 15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums? Yes___ No___ 16. Do you like your smile?
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 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 authorize and request my insurance company to pay
directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier
may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my
dependants.
_____________________________________________________ ____________________ Signature of patient (or parent/guardian of minor) Date

Source: http://www.graywhiteandallendental.com/userfiles/7659/pdf/New_pt_form.pdf