P A T I E N T

Patient First Name: M.I.

Patient Last Name:

Sex: male female Date of Birth (M/D/Y): Age:

Social Security:

Street:

City State:

Zip

Home Tel: Bus. Tel: Ext.

Dentist:

Orthodontist:

Physician:

Referred By:

Have you ever been a patient in our practice: Yes No

Method of Personal Payment: Cash Check Credit Card

A C C O U N T

Who will be responsible for your account? Self Spouse Father Mother Other

Name:

Social Security:

Home Tel: Street:

City State: Zip

Employer: Tel:

I N S U R A N C E

Student: Full Time Part Time Not

School Name

School Address

Status: Married Divorced Legally Separated Widow Single

Employed: Full Time Part Time Retired Not

Do you belong to a PPO or HMO? Yes No

PRIMARY DENTAL INSURANCE

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.: Group Name:

Insured Party: Relation:

Sex: MF

Date of Birth (MM/DD/YY):

Street: City: State:

Zip

Phone: Social Security:

ID No.:

PRIMARY MEDICAL INSURANCE

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.: Group Name:

Insured Party: Relation:

Sex: MF

Date of Birth (MM/DD/YY):

Street: City: State:

Zip

Phone: Social Security:

ID No.:

SECONDARY DENTAL INSURANCE

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.: Group Name:

Insured Party: Relation:

Sex: MF

Date of Birth (MM/DD/YY):

Street: City: State:

Zip

Phone: Social Security:

ID No.:

SECONDARY MEDICAL INSURANCE

Employer:

Address:

Bus. Tel:

Insurance Company Name:

Address:

Phone:

Group No.: Group Name:

Insured Party: Relation:

Sex: MF

Date of Birth (MM/DD/YY):

Street: City: State:

Zip

Phone: Social Security:

ID No.:

Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today's visit:

		YES	NO
Are you in good health:
Height:	Weight:
Have there been any changes in your general health in the past year?
Are you under the care of a physician?
Date of last visit: If so, for what are you being treated?
Have you had any illness, operation or been hospitalized in the past five years?
Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth?
If so describe where:
Do you have a prosthetic joint?
If so describe where:
Do you have a vascular graft?
If so describe where:

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