New Patient Forms (Adult) - Walnut Creek Dental

Patient Full Name *

First

Middle

Last

Gender *

Male
Female

Birth Date *//

Address

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number

Phone

Employer's Name

Occupation

Marital Status

Single
Married
Divorced
Widowed
Significant Other

Emergency Contact Name *

First

Last

Relationship to Patient *

Emergency Contact Address

Same as Patient

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Phone Number *

This person is authorized to receive appointment and medical information concerning the patient *

Primary Insurance Company *

Insurance Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

First

Last

Policy Holder's Relationship to Patient

Policy Holder's Birth Date//

Policy Holder's Social Security Number

Policy Holder's Employer

Policy Holder's Work Phone Number

Does the Patient Have Secondary Insurance?

Secondary Insurance Company

Secondary Insurance Phone Number

Secondary Insurance Group Number

Secondary Insurance Policy Number

Secondary Insurance Member ID Number

Secondary Insurance Policy Holder's Name

First

Last

Secondary Insurance Policy Holder's Relationship to Patient

Secondary Insurance Policy Holder's Birth Date//

Secondary Insurance Policy Holder's Social Security Number

Secondary Insurance Policy Holder's Employer

Secondary Insurance Policy Holder's Work Phone Number

How did you hear about our practice?

Ad
Internet Search
Family or Friend
Physician
Other

Name of person referring (if applicable)

Have your tonsils or adenoids been removed?

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Do you have any missing or extra permanent teeth?

Have you ever had an injury to (select all that apply)?

Teeth
Mouth
Chin

Do you have speech problems?

If yes, please explain

Do your gums bleed?

Do you smoke?

Do you like your smile?

Do you currently or have you ever had any of the following habits?

Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problems

Are you currently being treated by a physician? *

Physician Name

First

Last

Physician Phone

Date of Last Visit

Reason for Physician Visit

Do you have any allergies/sensitivities to medications or latex?

If yes, please list allergies

Are you currently taking any prescription or over-the-counter medications?

Please list any medications taken, along with dosage

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Have you had any serious illnesses or operations? If yes, please describe:

Have you ever had a blood transfusion?

If yes, give approximate dates:

Are you pregnant?

Are you nursing?

Are you taking hormonal birth control?

Check if you have or have ever had any of the following:

Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Patient Signature and/or Responsible Party *

Today's Date *