CONFIDENTIAL PATIENT INFORMATION               Date:______________


Please fill in your answers as thoroughly as possible.   All information is confidential.


Name:________________________________________________________      ____________________________________                                    

                (Last)                                                           (First)                            (MI)                   (I prefer to be called…)


     (circle one)    Single     Married     Widowed      Separated      Divorced      Partnered


     (check one)    Male______     Female______                    Social Security # ______________________________________


Date of Birth_____________________________                 Driver’s License #_____________________________________



                 (No.)             (Street)                                         (City)                      (State)                                    (Zip code)


E-Mail Address:_______________________________________________________________________________________


Telephone #’s:________________________________________________________________________________________

                        (Home)                               (Work)                                       (Cell)                                         (Other)


Occupation:________________________________________   Employer:_________________________________________


Employer Address:_____________________________________________________________________________________


Best phone # to confirm your dental appointments? ____________________________


Do you prefer your confirmation by e-mail?   Yes____ No____




Name of spouse / partner_______________________________     Occupation: _____________________________________


Spouse/Partner employed by: _____________________________________________________________________________


Employer Address: _____________________________________________________________________________________


Number of children in family: ________          Ages:__________________________________________________________




Primary Dental Insurance Coverage? Yes___ No___            |   Secondary Dental Insurance Coverage?  Yes___ No___


Insurance Co. Name:______________________________   |   Insurance Co. Name:__________________________________


Ins. Co. Address: _________________________________ |   Ins. Co. Address:_____________________________________


Ins. Co. Phone #: _________________________________ |   Ins. Co. Phone #: _____________________________________


Group # (Plan, Local or Policy #): ___________________   |   Group # (Plan, Local or Policy #): _______________________


Insured’s Name__________________________________   |   Insured’s Name______________________________________


Relation: _______________________________________   |   Relation: ___________________________________________


Insured’s Birthdate: ______________________________    |   Insured’s Birthdate: __________________________________       


Insured’s SS #: __________________________________  |   Insured’s SS #: ______________________________________


Insured’s Employer:______________________________    |   Insured’s Employer:___________________________________


Employer Address: ______________________________    |   Employer Address: ___________________________________


______________________________________________    |   ___________________________________________________

     City                            State                         Zip                   |               City                          State                            Zip







Payment is due in full at the time of treatment unless prior arrangements have been approved.


If you are covered by an insurance plan, we are happy to file the claims for you. Your deductible and co-payments are due at the time of service.  After 30 days, the balance for  any unpaid claims are your responsibility. 




I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself to third party insurance carriers, payors and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.


I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).



Signature___________________________________________________                          DATE:  __________________










I have been presented with a copy of this practice’s Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the Notice, and I request the following restriction(s) concerning the use of my personal medical information:


[ ]    I give permission to share information with: (name)  ___________________________________________________


         Please check:        ____ Spouse     _____ Family Member    _____ Friend     _____Other


[ ]   I do not give permission to share information.



Further, I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to medical assignment of benefits apply.




Signature___________________________________________________                          DATE:  __________________



If you are not the patient, please indicate relationship to patient (i.e., parent, spouse, guardian, partner).



Relationship:________________________________________________         Witnessed by:_______________________________________






_____ Patient refused to sign this Acknowledgement.


Date:_________________________ Time:_______________________



Employee name:__________________________________________



                                                              MEDICAL  HISTORY                                       Date____________


Name_________________________________        DOB____________ 


Under a physician’s care  now?   ……………. ………Yes___ No___          Date of your last medical checkup:________________
Ever been hospitalized, or had a major illness? .….. …. Yes___ No___ …> If yes…Please Explain:

 | 3. Women:  Are you…                                                                                  |

 |       Pregnant / Trying to get pregnant?    Yes___ No___                         |      

 |             Due Date ______________                                                            |

 |         Nursing…………………………..    Yes___ No___                           |

 |         Taking oral contraceptives? …..…    Yes___ No___                            |



Do you have or have you had any of the following conditions? … If ‘Yes’ please explain below.

AIDS/HIV Positive                  Yes___ No___   |    Breathing / Lung Problems     Yes___ No ___  |   High Blood Pressure                                Yes___ No___

Alzheimer’s Disease               Yes___ No___   |    Cancer / Chemo / Radiation     Yes___ No ___  |   Kidney Problems                                               Yes___ No___  

Anemia                                  Yes___ No___   |    Congenital Heart Disorder      Yes___ No ___  |   Liver Disease /Yellow Jaundice                    Yes___ No___  

Arthritis / Gout                      Yes___ No ___  |    Diabetes                                  Yes___ No___   |   PsychiatricCare / Depression                             Yes___ No___

Artificial Heart Valve               Yes___ No___   |    Epilepsy or Seizures                Yes___ No___   |   Stomach / Intestinal Disease                    Yes___ No___

Artificial Joint                         Yes___ No___   |    Heart Pacemaker                     Yes___ No___   |   Thyroid Disease  Asthma                                    Yes___ No___   |    Heart Trouble / Heart Disease Yes___ No___   |

Blood Disease / Transfusion      Yes___ No ___  |    Hepatitis                                 Yes___ No___   |


Do you have any other serious illness, condition or problem not listed above?    Yes___ No___


Currently taking any medications, pills or drugs? ……..Yes___ No___ ….> Please List Meds:






Are you allergic to any of the following?-------------------------------------------------------------------------------------------------------------------------------

      Aspirin___       Penicillin___     Codeine___       Local Anesthetics___    Acrylic___     Metals___       Latex___              Sulfa drugs___


     Any other allergies?   ____ none   ______ if yes, please list:




7 . Ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?...Yes___ No___

Have you used controlled substances ?...Yes___ No___

Who is your primary care physician?________________________________  10. Other medical providers / specialty:
                                                Phone #: _______________________________ 

Pharmacy: ___________________________________________________ 
  Phone #:_________________                             


Additional Information:







                                                           DENTAL  HISTORY                                                                Date____________


Name_________________________________        DOB____________ 



Reason for today’s visit___________________________________   |     Do you have any other dental concerns? Yes___ No___

|           If ‘Yes” please explain…

Former Dentist__________________________________________   |                               `                                                              


       City / State_________________________________________     |


Approximate date of last dental visit_________________________     |


Approximate date of last dental x-rays________________________    |


Have you ever had:

              Orthodontic treatment?                           Yes___ No___        |     Periodontal treatment?                                       Yes___ No___                                        Trouble with dental treatment before?     Yes___ No___        |     Anxiety / Fear with dental treatment?                Yes___ No___

Dental appliances?                Yes___ No___   Night guard, TMJ appliance, Ortho retainers, Snoring / Sleep Apnea             ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------


Place a mark on ‘yes’ or ‘no’ to indicate if you have had or do any of the following:


Bad breath                                  Yes___ No___     | Food catching between teeth  Yes___ No___     

Sensitivity to cold                       Yes___ No___

Bleeding Gums                            Yes___ No___       | Foreign objects in your mouthYes___ No___     

Sensitivity to heat                       Yes___ No___  

Blisters on lips or mouth             Yes___ No___       | Gums swollen or tender         Yes___ No___     

Sensitivity to sweets                   Yes___ No___

Burning sensation on tongue        Yes___ No___      | Herpes / Cold Sores              Yes___ No___     

Sensitivity when biting                Yes___ No___

Chew on one side of the mouth    Yes___ No___     | Lip or cheek biting Yes___ No___      

Sores or growths in your mouth    Yes___ No___

Dry mouth                                   Yes___ No___     | Loose teeth or broken fillings Yes___ No___        Tobacco Use     

Fingernail biting                         Yes___ No___     | Mouth pain when brushing   Yes___ No___      | Whitening treatments                                 Yes___ No___



  Are you happy with the appearance of your teeth?   Yes___ No___

How often do you brush? _________________    |   What would you like to change if you could ?


How often do you floss? _________________     |




TMJ Questionaire


Are you aware of clenching your teeth?                  Yes___ No___            

Are you aware of grinding your teeth?                     Yes___ No___  

Do you have frequent or regular headaches?            Yes___ No___          

Are your jaw muscles sore or tender?                       Yes___ No___  

Uponwakening?                                                       Yes___No___                                                 

Do your jaw and/or facial muscles feel tired?            Yes___ No___

Late afternoon?                                                        Yes___No___                                           

 Have you ever had injury to your face or jaw?          Yes___ No___

Does either jaw joint make noise?                             Yes___ No___        |         If ‘Yes’ describe:                                                                         

              …Grating?                 Yes___ No___                                   |  

…Grinding?               Yes___ No___                                    |

…Clicking?                Yes___ No___                                    |     Do your jaw joints lock when trying to open or close?     Yes___ No___

…Popping?                Yes___ No___                                    |     Are any teeth sensitive, sore, aching or uncomfortable?     Yes___ No___

Have you ever worn a splint or night guard?          Yes___ No___        |     Have you taken medications for these symptoms?            Yes___ No___

                …If ‘Yes’ how many?   ____                                                 |         If ‘Yes’ describe:

Is there frequent pain in any of the following areas?                                                                                                                                                                 

   Ear        Yes___ No___        |   Face        Yes___ No___                                                                                                                                             

   Head     Yes___ No___        | Neck        Yes___ No___                   

                                                | Shoulder   Yes___ No___                  


Have you seen a dentist / TMJ specialist for the symptoms?     Yes___ No___    







I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.