Patient Information Personal InformationName First Last Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneEmail Birth Date Date Format: MM slash DD slash YYYY SexMaleFemaleMarital StatusSingleMarriedDivorcedSeparatedWidowedSpouse NameOccupationReferred by:Person Responsible for AccountName First Last Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dental Insurance InformationPrimary Insurance Co.Insurance Co. AddressEmployeeRelationshipSS#Employer :Policy #:Secondary Insurance Co.Insurance Co. AddressEmployeeRelationshipSS#Employer :Policy #:Consent*I understand that payment is my obligation regardless of insurance or any other third-party involvement. I agree.Health InformationPersonal Physician NamePersonal Physician Address1. Have you been hospitalized within the past 2 years?YesNoFor What?2. Are you currently being treated by a physician?YesNoFor What?3. Are you currently taking any medications or drugs?YesNoFor What?4. Have you ever received counseling for excessive use of alcohol and/or prescription drugs?YesNo5. Are you allergic to any drugs?YesNoWhat?6. Have you ever had a skin rash or other reaction to metal jewelry?YesNoTo what?7. Are you allergic to any metals?YesNoTo what?8. Do you bleed excessively upon injury?YesNo9. Are you pregnant?YesNo10. Have you ever been involved with dental/medical legal activity?YesNoCheck any of the following conditions that you have had or now have AIDS Arthritis Asthma Cancer Diabetes Epilepsy Glaucoma Heart Murmur Hear Problem Hepatitis High Blood Pressure Jaundice Kidney Problems Low Blood Pressure Nervous Breakdown or Psychiatric Therapy Osteoporosis Rheumatic Fever Sexually Transmitted Diseases Stroke Tuberculosis Other Person to Be Contacted in Case of Emergency (Other Than Relative)Name First Last AddressHome PhoneWork PhoneCAPTCHA
