WELCOME

Patient Information
Name_______________________________SS #______________________Date _______________________
First               MI            Last
Address___________________________City_________________________State_______ Zip_________
Birthdate_________ Home Ph._______________Work Ph.______________ Cell Ph. _______________
Email Address____________________________________
Are you:      Minor       Married       Divorced       Widowed       Single       Separated
Employer_____________________________________________Occupation___________________________
Spouse or Parent's Name____________________ Employer_____________________ Phone_______________
How did you hear about us? (Referral, newspaper, yellow pages, etc.) ______________________________
If referral, whom may we thank?________________________________
Responsible Party (Please present insurance card to receptionist)
Person responsible for account_______________________ SS #______________ Birthdate___________
Relationship to patient________________ Home Phone_______________ Work Phone______________
Address_________________________________ City____________________ State_________ Zip_________
Dental History
Former Dentist_____________________ Date of last exam___________ Date of last xrays___________
Reason for today's visit_______________________________________________________________________
How often do you brush?________________________ How often do you floss?_________________
Please check any of the following conditions that apply to you:
Bad Breath	Grinding Teeth	Sensitivity to hot
Bleeding Gums	Loose teeth or broken fillings	Sensitivity to sweets
Clicking or popping jaws	Periodontal Treatment	Sensitivity when biting
Food collection between teeth	Sores or growths in mouth	Sensitivity to cold

(Close this window to return to our site).