PatientInformation RecordPlease enable JavaScript in your browser to complete this form.Patient's Personal InformationPatient's Name *FirstMiddleLastPatient's DOB *AgePatient AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeContact # (Cell)Contact # (Home)Contact # (Work)Email *Dentist NameInsurance InformationCompanyPlan NumberCert/ID NumberParent's, Spouse or Legal Guardian Details (if under the age of 18)Full NameFirstLastRelationship to PatientAddress (leave empty if same as above)Address Line 1CityState / Province / RegionPostal CodeContact # (Cell)Contact # (Home)Contact # (Work)DOBEmailFull NameFirstLastRelationship to PatientAddress (leave empty if same as above)Address Line 1CityState / Province / RegionPostal CodeContact # (Cell)Contact # (Home)Contact # (Work)DOBEmailHealth Information1.Is the patient in good health? *YesNo2.Is the patient on any medications? If so, please list *YesNoMedications3.Does the patient have or ever had heart trouble, diabetes, asthma, kidney or liver involvement, epilepsy or bleeding disorders, HIV or AIDS? Please list any condition not mentioned above *YesNoMedical Conditions4.Has the patient experienced any unfavorable reactions to medicines such as Penicillin, Aspirin, Novocain? *YesNoReactions to5.Does the patient have a latex allergy? *YesNoList any other allergies6.Is there any history of thumb or finger sucking? *YesNo7.Is there a history of mouth breathing or tongue thrusting? *YesNo8.Has the patient ever had a pain, clicking or locking of the jaw joint (TMJ)? *YesNo9.Is there a hereditary background that might contribute to the problem? *YesNo10.Has the patient had any unexplained weight loss in the last 90 days? *YesNo11.In the past 90 days has the patient had an elevated temperature, night sweats, loss of appetite, lack of energy, swollen glands, prolonged hoarseness, sore throat, soreness in the mouth? If yes, underline condition *YesNoConditionWhat, if anything, makes you unhappy about your teeth?Is there anything else we need to know?Signature (Block letters)DateSubmit1141
