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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
Month
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Day
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2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
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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
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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
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Phone
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Employer
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State
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Birthdate
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
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Year
1924
1925
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1927
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1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
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Employer Phone
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Zip Code
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Employer Address
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Responsible Party Spouse
(if different from patient)
Name
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Birthdate
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
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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
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Relationship to Patient
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ID#
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Carrier Name & Address
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Insurance Phone:
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Do you have secondary Insurance
Yes
No
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Employer:
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If Yes:
Group #:
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Insured's Name:
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Relationship to Patient:
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ID#:
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Carrier Name & Address
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Insured's Phone
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Employer
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Group #
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Emergency Contact (NOT living with patient)
Name
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Relationship to patient
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Phone
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Please Note: 24 Hour Notice is Required for Cancellation to Avoid a Charge
< Prev
Next >
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
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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
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Notes:
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Date
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Submit Form
< Prev
Submit 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
Invalid Input
Do you ever wear contact lenses?
Yes
No
Invalid Input
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
Invalid Input
Tranquilizers
Yes
No
Invalid Input
Insulin, Orinase or similar drug
Yes
No
Invalid Input
Aspirin
Yes
No
Invalid Input
Digitalis or drugs for heart trouble
Yes
No
Invalid Input
Nitroglycerin
Yes
No
Invalid Input
Cortisone (steroids)
Yes
No
Invalid Input
Natural remedies
Yes
No
Invalid Input
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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