New Patient Forms

Patient Forms

Patient Information

First Name

Last Name

Preferred Name

Middle Initial

Address

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Gender

Marital Status

Today's Date

Date of Birth

Home Phone #

Work Phone #

Cell Phone #

Cell Phone Carrier

For Text Confirmations

Preferred contact method

Preferred contact method for recall

Preferred contact method for confirmations

Primary Insurance Information

Check this box if same for entire family

Insurance Name

Relationship to Patient

Policy Holder

Date of Birth

ID #

Group #

Insurance Phone #

Do you have a Secondary Insurance?

Employer

Insurance Address

Street Address (line 1)

Street Address (line 2)

City

State/Province

Zip/Postal

Whom may we thank for referring you?

Emergency Contact / Responsible Party Information

(will only be used for office communications)

Name

Date of Birth

Address

Street Address (line 1)

Street Address (line 2)

City

State/Province

Zip/Postal

Home Phone #

Cell Phone #

Work Phone #

Relationship to Patient

Is this person currently a patient in our office?

Patient Medical History

Latex Allergy

Are you currently taking bisphosphonates?

Primary Care Physician

Phone #

Date of Last Exam

Have you ever been told you have one of the following?

Heart Disease

Yes

Bleeds Easily

Yes

Fainting/Seizures

Yes

Hay Fever/Allergies

Yes

Kidney Disease

Yes

Liver Disease

Yes

Hepatitis

Yes

Jaundice

Yes

Anemia

Yes

Swollen Ankles

Yes

AIDS/HIV

Yes

Emphysema

Yes

Rheumatic Fever

Yes

Stomach Ulcer

Yes

Thyroid Disease

Yes

Ashma

Yes

Heart Attack

Yes

Arthritis

Yes

Cancer

Yes

Diabetes I

Yes

Diabetes II

Yes

Stroke

Yes

Cancer in Remission

Yes

Heart Murmur

Yes

Shortness of Breath

Yes

Chest Pain - Angina

Yes

Epilepsy/Convulsions

Yes

High Blood Pressure

Yes

Low Blood Pressure

Yes

Leukemia

Yes

Glaucoma

Yes

Congenital Heart Defect

Yes

Joint Replacement/Implant

Yes

If yes, when?

Recent Weight Loss

Yes

Psychiatric Treatment

Yes

Radiation Therapy

Yes

Mitral Valve Prolapse

Yes

Do you have any allergies to any medications?

Are you under any medical treatment now?

Yes

Please explain

Have you ever had any other serious illness not listed above?

Yes

Please explain

Are you currently taking any medications?

Yes

Please explain

Have you ever had a bad reaction to local anesthetic or penicilin?

Yes

Please explain

Do you use tobacco?

Yes

Please explain

Do you use alcohol, cocaine, or other drugs?

Yes

Please explain

(for women only) Are you pregnant or think you may be pregnant?

Yes

Please explain

(for women only) Are you currently using birth control?

Yes

Patient Dental History

Previous Dentist

Phone #

Date of Last Exam

Location

Date of Last Cleaning

What is the reason for your visit today?

Do you have any pain or discomfort now? If so, please explain

How many times per day do you brush your teeth?

How often do you floss?

Are your teeth sensitive to hot or cold liquids?

Are your teeth sensitive to sweet or sour liquids?

Have you ever worn braces?

Do you wear dentures?

Have you ever had trauma to your face or mouth?

Have you ever had prolonged bleeding after extractions?

Do you clench or grind your teeth?

Do you bite your lips or cheeks frequently?

Do you have any sores or lumps in or around your mouth?

Have you ever had a root canal?

Do you have dental implants?

I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

I understand that I am responsible for any account balance and payment in full is expected at the time of service, unless prior arrangements have been made. I authorize and request my insurance company to pay directly to Elite Smiles Dental any insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services and Elite Smiles Dental has no leverage on assuring that my claims will be be paid as estimated. As a courtesy to their patients, Elite Smiles Dental completes and files my insurance claims for me. I understand that I am responsible for any unpaid or denied claims. Thank you for understanding that as your dental care provider, our relationship is with you and not with your insurance company.

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I understand that Elite Smiles Dental complies with all HIPAA policies and regulations and that I may request a detailed outline of such policies.

Name of Patient

Signature of Patient, Parent, or Guardian

Clear

Today's Date

If you are human, leave this field blank.

Patient Information

Primary Insurance Information

Emergency Contact / Responsible Party Information

Patient Medical History

Patient Dental History

Looking forward to giving you the smile that lights up the room!