New Patient Information
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What is your full name? *
Do you have a preferred name?
What is your date of birth? *
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DD
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What is your gender? *
Social Security Number?
Drivers Licence Number?
Mailing Address *
Phone Number *
Email *
Who were you referred by?
Employer and how long have you worked there?
Employer's Address
Occupation
Spouse's Name
Name of Person Ultimately Responsible for Account
Relation to Patient
Birth date
MM
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DD
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YYYY
Age
Gender
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Social Security Number
Drivers License Number
Billing Address
Phone Number
Email
Primary Dental Insurance Name *
Primary Dental Insurance Address *
Primary Dental Insurance Phone Number *
Primary Dental Insurance Insured ID # *
Primary Dental Insurance Group # (Plan, Local or Policy #) *
Insured's Named
Insured's Date of Birth
MM
/
DD
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YYYY
Insured's Employer
In the Event of an Emergency who should we contact? (Name, Relation to Patient, Phone Number) *
Who is your Medical Doctor and What is their Phone Number?
Please Indicate if you have any of the following problems: *
Required
Do you require pre-medication? *
Name of Previous Dentist and Their Phone Number
Last Dental Exam
MM
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DD
/
YYYY
Last Dental X-rays
MM
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DD
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YYYY
Times a week you brush? *
Times a week you floss? *
What medications are you taking? *
Have you ever taken Bisphosponates? *
Have you ever taken Phen-fen/Redux? *
Please indicate if you have or have had any of the following diseases, conditions, or procedures: *
Required
Please list any other surgeries or medical conditions you have or ever had:
Are you allergic to any of the following? *
Required
If you answered "foods" in the previous question, what kind?
Do you use tobacco? *
If yes, how much used, and for how long?
For Women: Are you taking Birth Control Pills?
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For Women: How many children have you had?
For Women: Are you pregnant?
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If yes, how long?
Are you nursing?
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Reason for today's visit? *
Required
Are you in pain? *
If yes, how long have you been in pain?
Do you give permission to The Dental Place to leave information on your answering machine/ or with any family members in regard to treatment plans, referrals, test results, and/or billing and payment information? If you choose not to authorize any family members or friends for disclosure of PHI, DDA will not be able to release any information, including appointment or patient billing questions to anyone other than the patient. *
If yes, who is allowed for the Dental Place to release your health information to?
Cancellation Policy/ No Show Policy: We Understand that there are times when you must miss an appointment due to emergencies or obligations. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. If an appointment is not cancelled, at least 24 hours in advance, you will be charged a fee of fifty dollars ($50). This fee will not be covered by your insurance company. Please sign with your full name and today's date. *
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