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(360) 887-2310

Office Hours

Mon–Tues: 8 AM - 5 PM
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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SSN

Invalid Input

Referred By

Work Phone #

Invalid Input

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

Invalid Input

Middle Initial

Invalid Input

Relationship to patient:

Self

Spouse

Parent

Guardian

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Address

Invalid Input

City

Invalid Input

Phone

Invalid Input

Employer

Invalid Input

State

Invalid Input

Birthdate

Month010203040506070809101112

Day01020304050607080910111213141516171819202122232425262728293031

Year1924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008

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Employer Phone

Invalid Input

Zip Code

Invalid Input

SSN

Invalid Input

Employer Address

Invalid Input

Responsible Party Spouse

(if different from patient)

Name

Invalid Input

Birthdate

Month010203040506070809101112

Day01020304050607080910111213141516171819202122232425262728293031

Year1924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005

Invalid Input

SSN

Invalid Input

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

Invalid Input

Heart valve problem

Yes

No

Invalid Input

Taking heart medication

Yes

No

Invalid Input

Rheumatic fever

Yes

No

Invalid Input

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

Invalid Input

Taking allergy medication

Yes

No

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Asthma

Yes

No

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Intestinal Problems

Yes

No

Invalid Input

Ulcers

Yes

No

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Weight gain or loss

Yes

No

Invalid Input

Special Diet

Yes

No

Invalid Input

Constipation/Diarrhea

Yes

No

Invalid Input

Kidney or bladder problems

Yes

No

Invalid Input

Bone or Joint Problems

Yes

No

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Arthritis

Yes

No

Invalid Input

Back or neck pain

Yes

No

Invalid Input

Joint replacement

Yes

No

Invalid Input

Fainting Spells, Seizures or Epilepsy

Yes

No

Invalid Input

Stroke(s)

Yes

No

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Frequent or severe headaches

Yes

No

Invalid Input

Thyroid problems

Yes

No

Invalid Input

Persistent cough or swollen glands

Yes

No

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Premedication required by physician

Yes

No

Invalid Input

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

Invalid Input

Barbiturates, sedatives, or sleeping pills

Yes

No

Invalid Input

Aspirin, Acetaminophen or Ibuprofen

Yes

No

Invalid Input

Codeine, Demerol or other narcotics

Yes

No

Invalid Input

Reaction to metals

Yes

No

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Latex or rubber dam

Yes

No

Invalid Input

Other

Invalid Input

Notes:

Invalid Input

Date

Invalid Input

Submit Form

< PrevSubmit Form

Diabetes

Yes

No

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Urinate more than 6 times a day

Yes

No

Invalid Input

Thirsty or mouth is dry much of the time

Yes

No

Invalid Input

Family history of diabetes

Yes

No

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Tuberculosis or other respiratory disease

Yes

No

Invalid Input

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

Invalid Input

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

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Insulin, Orinase or similar drug

Yes

No

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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

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Nonprescription drug/supplements

Yes

No

Invalid Input

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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