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.