Submit Patient Info

Patient Information

Date

Sex: Male Female

First Name

Middle Initial

Last Name

Mobile Phone

Work Phone

Home Phone

Mailing Address

City

State

Zip

Date of Birth

SSN

Employer

Person Responsible for Account

First Name

Middle Initial

Last Name

Date of Birth

SSN

Drivers License #

Emergency Contact

Relationship

Mobile Phone

Work Phone

Mailing Address

City

State

Zip

Primary Insurance

Insurance Co.

ID #

Group #

Phone #

Employer

Primary Policy Holder

DOB

SS#

Relationship

Secondary Insurance

Insurance Co.

ID #

Group #

Phone #

Employer

Primary Policy Holder

DOB

SS#

Relationship

Medical History

Name

DOB

Allergies / Reactions
I have no medication allergies

Medications/Dosage/Condition
I take no medication

Please include aspirin / blood thinners, fish oil, supplements or vitamins.

If Other Please List

Are you pregnant or nursing? (how many months if so)

Have you had any surgeries? (which?)

Has your medical doctor recommended antibiotics before dental care?

Do you use tobacco? (If so how long?)

Submit

Patient Information

Person Responsible for Account

Primary Insurance

Secondary Insurance

Medical History

Do you have/or ever had any of the conditions listed below?

Patient Screening Form