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Office Hours

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Wed–Thu: 7 AM - 4 PM

Page 1 of 3

Patient Information

Prefix

Mr.

Mrs.

Ms.

Miss

Dr.

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Last Name

Please type your last name.

First Name

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Middle Initial

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Home Address

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City

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State

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Zip Code

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Billing Address

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Home Phone #

Invalid email address.

Email Address

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Referred By

Work Phone #

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Birthdate

Month010203040506070809101112

Day01020304050607080910111213141516171819202122232425262728293031

Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019

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Cell Phone #

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Male or Female

Male

Female

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Patient

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Doctor

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Other

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Next >

Responsible Party Information

Last Name

Invalid Input

First Name

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Middle Initial

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Relationship to patient:

Self

Spouse

Parent

Guardian

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Address

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City

Invalid Input

Phone

Invalid Input

Employer

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State

Invalid Input

Birthdate

Month010203040506070809101112

Day01020304050607080910111213141516171819202122232425262728293031

Year1924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008

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Employer Phone

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Zip Code

Invalid Input

Employer Address

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Responsible Party Spouse

(if different from patient)

Name

Invalid Input

Birthdate

Month010203040506070809101112

Day01020304050607080910111213141516171819202122232425262728293031

Year1924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005

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Payment Options

(Choose One, if no option is checked, Payment in full is assumed choice)

Payment option

Pay-in-full at each visit (We offer a cash discount)

Pay my Co-Payment at each visit - as a courtesy we will bill insurance. Responsible party agrees to pay whatever insurance does not cover.

Care Credit Payment Plan (on approved credit through CareCredit)

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Dental Insurance Information

Insured's Name

Invalid Input

Relationship to Patient

Invalid Input

ID#

Invalid Input

Carrier Name & Address

Invalid Input

Insurance Phone:

Invalid Input

Do you have secondary Insurance

Yes

No

Invalid Input

Employer:

Invalid Input

If Yes:

Group #:

Invalid Input

Insured's Name:

Invalid Input

Relationship to Patient:

Invalid Input

ID#:

Invalid Input

Carrier Name & Address

Invalid Input

Insured's Phone

Invalid Input

Employer

Invalid Input

Group #

Invalid Input

Emergency Contact (NOT living with patient)

Name

Invalid Input

Relationship to patient

Invalid Input

Phone

Invalid Input

Please Note: 24 Hour Notice is Required for Cancellation to Avoid a Charge

< PrevNext >

Medical Health History:

Do you have, or have had, any of the following?

Heart Problems

Yes

No

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Chest pain

Yes

No

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Shortness of breath

Yes

No

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Blood pressure problem

Yes

No

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Heart murmur

Yes

No

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Heart valve problem

Yes

No

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Taking heart medication

Yes

No

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Rheumatic fever

Yes

No

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Pacemaker

Yes

No

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Artificial heart valve

Yes

No

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Blood Problems

Yes

No

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Easy bruising

Yes

No

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Frequent nosebleeds

Yes

No

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Abnormal bleeding

Yes

No

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Blood disease (anemia)

Yes

No

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Ever require a blood transfusion ?

Yes

No

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Allergy Problems

Yes

No

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Hey Fever

Yes

No

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Sinus problems

Yes

No

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Skin rashes

Yes

No

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Taking allergy medication

Yes

No

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Asthma

Yes

No

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Intestinal Problems

Yes

No

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Ulcers

Yes

No

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Weight gain or loss

Yes

No

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Special Diet

Yes

No

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Constipation/Diarrhea

Yes

No

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Kidney or bladder problems

Yes

No

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Bone or Joint Problems

Yes

No

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Arthritis

Yes

No

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Back or neck pain

Yes

No

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Joint replacement

Yes

No

Invalid Input

Fainting Spells, Seizures or Epilepsy

Yes

No

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Stroke(s)

Yes

No

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Frequent or severe headaches

Yes

No

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Thyroid problems

Yes

No

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Persistent cough or swollen glands

Yes

No

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Premedication required by physician

Yes

No

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Cancer/Tumor

Yes

No

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Are you allergic, or have you reacted adversely to any of the following?

Local anesthetics ("Novocaine")

Yes

No

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Penicillin or other antibiotics

Yes

No

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Sulfa drugs

Yes

No

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Barbiturates, sedatives, or sleeping pills

Yes

No

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Aspirin, Acetaminophen or Ibuprofen

Yes

No

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Codeine, Demerol or other narcotics

Yes

No

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Reaction to metals

Yes

No

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Latex or rubber dam

Yes

No

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Other

Invalid Input

Notes:

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Date

Invalid Input

Submit Form

< PrevSubmit Form

Diabetes

Yes

No

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Urinate more than 6 times a day

Yes

No

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Thirsty or mouth is dry much of the time

Yes

No

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Family history of diabetes

Yes

No

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Tuberculosis or other respiratory disease

Yes

No

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Do you drink alcohol?

Yes

No

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If so how much

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Do you smoke?

Yes

No

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If so how much?

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Hepatitis, jaundice, or liver trouble

Yes

No

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Herpes or other STD

Yes

No

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HIV-positive/AIDS

Yes

No

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Glaucoma

Yes

No

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Do you ever wear contact lenses?

Yes

No

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Epilepsy or other neurological disease?

Yes

No

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History of head injury?

Yes

No

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History of alcohol or drug abuse?

Yes

No

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Do you have any disease, condition, or problem not listed previously that you feel we should know about?

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During the last 12 months, have you taken any of the following?

Antibiotics or sulfa drugs

Yes

No

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Anticoagulants (e.g., Coumadin)

Yes

No

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High blood pressure medicine

Yes

No

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Tranquilizers

Yes

No

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Insulin, Orinase or similar drug

Yes

No

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Aspirin

Yes

No

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Digitalis or drugs for heart trouble

Yes

No

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Nitroglycerin

Yes

No

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Cortisone (steroids)

Yes

No

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Natural remedies

Yes

No

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Nonprescription drug/supplements

Yes

No

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Other

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Women

Are you taking contraceptives or other hormones?

Yes

No

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Are you pregnant?

Yes

No

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If so expected delivery date:

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Are you nursing?

Yes

No

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Have you reached menopause?

Yes

No

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If so, do you have any symptoms?

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Notes:

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