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New Patient Form

Patient's Name

Email

 

Office (For Office Use Only)

Age

 

Chart No (For Office Use Only)

Date

 

Dental History

Date of last dental visit

Date of last x-ray

 

Do you have an appliance(bridge, partial, dentures)?
YesNo (If yes, Age of appliance):

 

What would you like to discuss with the dentist today ?

 

Medical History

(Required Information)

Physician’s Name:

Telephone #

 

Are you in good health?YesNo (If no, please explain):

 

•Have you had a blood transfusion?
YesNo

 

•Have you taken weight loss medicine? (e.g. Fen-Phen)
YesNo

 

•Do you Smoke?
YesNo

•Use recreational drugs?
YesNo

•Use chewing tobacco?
YesNo

 

•Have you had prolonged bleeding?
YesNo

 

•If yes, check all that apply:
after an operationinjuryextractions

 

•Is there any family history of(check all that apply):DiabetesHeart murmur/problemsTumors

 

•Are you?(Women Only )PregnantNursingTaking birth control pills

 

•Have you ever had any of the conditions listed below? None
(Or Check all that apply)

AIDS/HIVAllergiesAnemiaAnginaArthritisArtificial JointArtificial Heart ValveAsthmaBack ProblemBleeding Disorder

CancerChemical DependencyChemotherapyCold SoresDiabetesDizzy SpellsEmphysemaEmotional DisorderEpilepsyFainting

Fever BlistersHeart BypassHeart MurmurHeart ProblemHeart SurgeryHepatitisHigh Blood PressureHIV PositiveImmunosuppressedJaundice

Kidney DiseaseLiver ProblemsLow Blood PressureLung DiseaseMitral Valve ProlapseNervous/Mental DisorderPacemakerPsychiatric CareRadiation Therapy

Rheumatic FeverScarlett FeverSinus TroubleStrokeThyroid ProblemTonsillitisTuberculosisUlcer

 

•Have you ever had any condition/problem not listed above? YesNo (If yes, please explain):

 

•Medications: Please list all medications you are taking.

•Allergies: Please list allergies to any medications
None (Or)

 
The above information is complete & accurate to the best of my knowledge. I will not hold my dentist or staff responsible for any omissions I have made in completing this form.
 

Patient signature/Responsible Party (if patient is a minor)

Date

 

Health history reviewed by

Date

 

Confidential Patient Information

(Please print clearly & be as thorough as possible.)

Patient Information

Name

Social Security

 

Street:

Suite:

 

City/State:

Zip:

 

Date of Birth:

Home Phone:

 

Employer Name:

Work Phone:

 

Cell Phone:

Email Address:

 

Responsible Party Information

(insurance carrier)

Name of insured

Social Security

 

Name of Insurance Co

Group #

 

Street:

Suite:

 

City/State:

Zip:

 

Date of Birth:

Home Phone:

 

Employer Name:

Work Phone:

 

Cell Phone:

 

Secondary Insurance Information

(complete this section if patient has dual coverage)

Name of insured

Social Security

 

Name of Insurance Co

Group #

 

Street:

Suite:

 

City/State:

Zip:

 

Date of Birth:

Home Phone:

 

Employer Name:

Work Phone:

 

Cell Phone:

Driver’s License #

 

Getting To Know You

Do you belong to the UCB campus?
YesNO
If yes, are you StaffStudentOther

 

UCB student ID (required)

 

How did you hear about us?

 

Emergency Contact List

Name

Phone Number


 

Insurance Patients Please Sign Below for Billing Purposes

I have reviewed the following treatment plan & fees. I agree to be responsible for all charges for dental services & materials not paid by my insurance plan, unless the treating dentist or dental elective has a contractual agreement with my plan prohibiting all or a portion of such charges to the extent permitted under applicable laws. I authorize release of any information relating to this claim. I hereby authorize payment of the dental benefits otherwise payable to me directly to the below named entity.

**To Be Signed On Your First Office Visit**

Signature

Phone

 

Date