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386-672-3988
TRUE FAMILY DENTISTRY SINCE 1991


Online Patient Form


About You


Today's Date
Full Name: Last
First
MI
Title
I prefer to be called:
Yes
No
Sex:
Male
Female
Birthdate:
Age:
Social Security #:
Civil Status:
Home Address: Street
City:
State:
Zip code:
Home Phone #:
Pager/ Car #:
Work Phone #:
Ext.
E-mail Address:
Driver Licence #:
Where & when are best times to reach you?
Whom may we Thank for referring you?
Other family members seen by us:
Employer:
How long there:
Occupation:
Employer's Address: Street
City:
State:
Zip code:

Neighbor or Relative not living with you

His/ Her Name:
Relation:
Work Phone #:
Home Phone #:
Address: Street
City:
State:
Zip code:

Person Responsible for Account if other then yourself

Name:
Relation:
Home Phone #:
Social Security #:
Employer:
Work Phone #:
Ext.
Driver Licence #:
Address: Street
City:
State:
Zip code:

Spouse Information


His / Her Name:
Birth Date:
Social Security #:
Employer:
Work Phone #:
Ext.
Driver Licence #:

Insurance Information


Primary Insurance
Medical Coverage?
Yes No
Dental Coverage?
Yes No
Orthodontic Coverage?
Yes No
Insurance Co. Name:
Phone #:
Group # (Plan, Local or Policy #):
Address: Street
City:
State:
Zip code:
Insured's Name:
Insured's Social Security #:
Insured's Birthday:
Relation:
Insured's Employer
Employer's Address: Street
City:
State:
Zip code:

Secondary Insurance
Medical Coverage?
Yes No
Dental Coverage?
Yes No
Orthodontic Coverage?
Yes No
Insurance Co. Name:
Phone #:
Group # (Plan, Local or Policy #):
Address: Street
City:
State:
Zip code:
Insured's Name:
Insured's Social Security #:
Insured's Birthday:
Relation:
Insured's Employer
Employer's Address: Street
City:
State:
Zip code:

About You


Why have you come to the dentist today?
Are you currently in pain?    Yes No
Do you need premedicated before dental treatment?    Yes No
Have you experienced problems associated with any previous dental work?    Yes No
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?    Yes No
Your dental health is    Good Fair Poor
Do you flush daily?    Yes No
Do you brush daily?    Yes No
Type of bristles on your toothbrush?    Hard Medium Soft
How long do you use a toothbrush before replacing it?
Do you use anything in addition to your brush and floss?    Yes No
If yes, what?

Medical History


Do you have a personal physician?    Yes No
Physician's Name?
Address: Street
City:
State:
Zip code:
Phone #
Date of last visit:
Your current physical health is:    Good Fair Poor
Are you currently under the care of a physician    Yes No
Please explain:
Do you smoke or use tobacco in any other form?    Yes No
Are you allergic to any of the following:
Asprin
Yes
No
Barbiturates
Yes
No
Codeine
Yes
No
Dental Anesthetics
Yes
No
Erythromycin
Yes
No
Jewelry
Yes
No
Latex
Yes
No
Penicillin
Yes
No
Sedatives
Yes
No
Sulfa Drugs
Yes
No
Tetracycline
Yes
No
Other
Yes
No
Please list additional drugs that cause allergic reactions:
For woman: Are you taking birth control pills?    Yes No
Are you pregnant?    Unsure Yes No
Week #
Are you nursing?    Yes No
Are you taking any of the following:
Acetaminophen
Yes
No
Antibiotics
Yes
No
Antihistomines
Yes
No
Aspirin
Yes
No
Blood Thinners
Yes
No
Blood Pressure Medication
Yes
No
Cold Remedies
Yes
No
Digitalis/ Heart Medication
Yes
No
Insulin/ Diabetes Drugs
Yes
No
Nitroglycerin
Yes
No
Recreational Drugs
Yes
No
Steroids/ Cortisone
Yes
No
Thyroid Medicine
Yes
No
Tranquilizers
Yes
No
If yes, how often and how many milligrams?
Are you taking any prescription / over-the-counter drugs not listed above?    Yes No
If yes, please list each one:
Do you or have you experienced the following:
Abnormal Bleeding
Yes
No
Alcohol Abuse
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Artificial Banes/ Joints
Yes
No
Artificial Valves
Yes
No
Asthma
Yes
No
Blood Transfusion
Yes
No
Cancer
Yes
No
Chemotherapy
Yes
No
Chicken Pox
Yes
No
Colitis
Yes
No
Congenital Heart Defect
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Abuse
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Fainting Spells
Yes
No
Fever Blisters
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Headaches
Yes
No
Heart Attack
Yes
No
Heart Murmur
Yes
No
Heart Surgery
Yes
No
Hemophilia
Yes
No
Hepatitis
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
HIV+ / AIDS
Yes
No
Hospitalized for Any Reason
Yes
No
Kidney Problems
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lupus
Yes
No
Mitral Valve Prolapse
Yes
No
Pocemaker
Yes
No
Persistent Cough
Yes
No
Psychiatric Problems
Yes
No
Radiation Treatment
Yes
No
Rheumatic Fever
Yes
No
Scarlet Fever
Yes
No
Seizures
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Problems
Yes
No
Stroke
Yes
No
Thyroid Problems
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Please list any serious medical condition(s) that you have experienced:

Authorizations


I affirm that the information I have given is correct to the best of my knoledge. It will be held in the strictest cnfidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessory dental services I may need.
Signature
Date

Insurance


I understand that my insurance is an agreement between my insurance company and me. I also understand that I am responsible for the balance of my dental account regardless of my insurance.
Signature
Date