Patient Information Form

Patient Information Form

Patient Information Form

Patient Information

Today's Date:
Gender:
Marital Status:

Address *

Mailing Address (if different)

Emergency Contact:

Medical Insurance Information (Please be prepared to present your card(s) and ID)

Primary Co:

Name of Primary Person Insured:

Secondary Co:

Medical History​​​​​​​

Primary Care Physician:​​​​​​​

Specialist Dr:​​​​​​​

Dentist:​​​​​​​

Indicate any of the following conditions you may have experienced

List all current Prescription Medications and the reason you are taking them​​​​​​​

Are you allergic to any medication?​​​​​​​

If so, what are you allergic to?

Do you currently smoke?​​​​​​​

Do you use oral tobacco?​​​​​​​

Have you had orthodontic?

Do you use alcohol?​​​​​​​

How often do you consume alcohol?

Do you use sedatives?​​​​​​​

Past Treatment?

I believe the information provided above to be complete and accurate. I authorize the release of a full report of examination findings, diagnosis, treatment programs, etc., to any referring or treating dentist or physician, and I authorize the release of any medical information to insurance companies for legal documentation necessary to process claims.