New Patient Information Form

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Chart #:__________
FOR OFFICE USE ONLY
Patient Information
Patient Name: _________________________________________________________ Date:_______________
Last
First
MI
Male
Female
Married
Single
Child
Other
_____________
Social Security #: ________________________________ Birth Date: _________________________________
Phone (Home): ________________ (Work): ________________ Ext:______ Best time to call: _____________
Preferred appointment times:
Morning
Afternoon
Evening
Any Time
M
T
W
T
F
S
Address: __________________________________________________________________________________
Street
Apartment #
__________________________________________________________________________________
City
State
Zip Code
Health Information
Date of Last Dental Visit: __________________ Reason for this visit:___________________________________
Have you ever had any of the following? Please check those that apply:
AIDS
Excessive Bleeding
Liver Disease
Stroke
Allergies __________
Fainting
Mental Disorders
Tuberculosis
__________
Glaucoma
Nervous Disorders
Tumors
Anemia
Growths
Pacemaker
Ulcers
Arthritis
Hay Fever
Pregnancy
Venereal Disease
Artificial Joints
Head Injuries
Codeine Allergy
Due date:_________
Asthma
Heart Disease
Penicillin Allergy
Radiation Treatment
Blood Disease
Heart Murmur
Respiratory Problems
OTHER:
Cancer
Hepatitis
_________________
Rheumatic Fever
Diabetes
High Blood Pressure
Rheumatism
Dizziness
Jaundice
Sinus Problems
_________________
Epilepsy
Kidney Disease
Stomach Problems
• Have you ever had any complications following dental treatment?
Yes
No
If yes, please explain:_______________________________________________________________________
• Have you been admitted to a hospital or needed emergency care during the past two years?
Yes
No
If yes, please explain:______________________________________________________________________
• Are you now under the care of a physician?
Yes
No
If yes, please explain:______________________________________________________________________
• Name of Physician: _______________________________________________ Phone:___________________
• Do you have any health problems that need further clarification?
Yes
No
If yes, please explain:______________________________________________________________________
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have
any change in my health, I will inform the doctors at the next appointment without fail.
_________________________________________________________________
___________________
Date:
Signature of patient, parent or guardian
Referral Information
Whom may we thank for referring you to our practice?
Another patient, friend
Another patient, relative
Dental Office
Yellow Pages
Newspaper
School
Work
Other__________________
Name of person or office referring you to our practice:______________________________________________

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