Health History Form

Patient Information

First Name *

Middle Name

Last Name *

If Patient is a minor, give parent or legal guardian’s name

Relationship to Patient

How did you hear about us? *

Email Address *

What factored into your decision to choose our office? (Please check all that apply) *

Referral Name

Please explain:

Gender *

Male

Female

Marital Status *

Single

Married

Widowed

Divorced

Date Of Birth(MM/DD/YYYY) *

Driver’s License # *

Street Address *

City

State

ZIP Code

Mailing Address (if different from above)

Street Address

City

State

ZIP Code

Home Phone *

Cell Phone

Work Phone

Occupation

Employer

Responsible Party

Self

Other

Nearest Relative in area not living with you:

Name of parent/guardian *

Nearest Relative Phone Number

Nearest Relative in area not living with you:

Insurance Information

Do you have insurance? *

Yes

No

If yes, are you the policy holder? *

Yes

No

Policy Holder Name *

Policy Holder Date Of Birth *

Policy Holder Social Security Number

Insurance Company *

Insurance Company Phone Number *

Employer *

Insurance Member ID # *

Dental History

Name of former Dentist

Date of last visit

Purpose of your visit *

Complete Examination

Pain

Other

Please explain *

Have you ever had a local anesthetic (Novocain, etc.)? *

Yes

No

Have you had an unfavorable reaction from a local anesthetic? *

Yes

No

Have you ever had any serious trouble associated with any previous dental treatment? *

Yes

No

Does dental treatment make you nervous? *

Yes

No

Would you desire to be pre-sedated? *

Yes

No

I certify that I have answered the above questions to the best of my ability. If there is any change to my medical status, I will inform the dentist. I consent to treatment as necessary or desirable to the care of the patient first named above, including, but no restricted to whatever medicine, performance of operations and conduct of laboratory, x-rays or other studies that may be used by the attending dentist, or qualified designate. I also acknowledge full responsibility for my payment and agree to pay in full, at the time of service, unless other arrangements are made with the Financial Department.

Disclaimer *

I HAVE READ AND UNDERSTAND THE ABOVE CONDITIONS OF TREATMENT AND AGREE TO THEIR CONTENT

Patient Information

Insurance Information

Dental History

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