Name (First,MI,Last): _______________________________________    Age: __________

Home Address: ___________________________________________________________

City: _______________________________________  State: ________  Zip: ___________

Home Phone: (____)____________________   Work Phone: (____)___________________

Employer: _________________________________   Occupation: ____________________

 Work Address: ____________________________________     Employed: __________Yrs.

City: ______________________________________  State: ________  Zip: ____________

Patient is:   [ ] Single  [ ] Married  [ ] Divorced  [ ] Widowed  [ ] Minor

Patient Birthday: ___/___/___     Gender:  M    F     Social Sec. #:  ______ - _____ - _______

Spouse: ___________________ Occupation: ______________  Children: ______________

In Emergency notify: ___________________________  Phone: (____)_________________

Referred by: ______________________________________________________________

FINANCIAL  INFORMATION

Payment by:         [ ] Check     [ ] Cash     [ ] Credit Card (Expires ___/___)      [ ] Trade

Visa/MasterCard/AMEX/Discover #: ____________________________________________

Person Responsible: __________________________  Driver's License#: _______________

Relationship: __________________________________ Work Phone: (____)____________

Home Address: ________________________________ Home Phone: (____)____________

City: _______________________________________  State: ________  Zip: ____________

INSURANCE  INFORMATION

[ ] No Dental Insurance

Employee: _____________________________    Employee Soc. Sec.#:_____ - ___ - _____

 Employer: ________________________________  Phone: (____)____________________

Insurer: ___________________________________  Phone: (____)____________________

Address: _________________________________City:__________  State: ____  Zip: _____

Employee Birthday: ____/____/____                 Group#/Local#: _________________________

Relationship to Employee:   [ ] Self  [ ] Spouse  [ ] Child  [ ] Other

f Full Time Student, School & City: ______________________________________________

Is there a Second Insurance?    Y    N               Phone: (____) ____________

 Insurer#2: ____________________________         Group#: ___________

 We need some facts about your health.

Confidential  Information

MEDICAL  INFORMATION

General Health:  [ ] Excellent   [ ] V.Good   [ ] Fair   [ ] Poor

Height: ________    Weight: ________ lbs.       Last Physical:   ___/___/___

Physician: ____________________________   Phone#: (____)_________________

Address & City: ______________________________________________________

ALLERGIC or Sensitive to:  [ ] Penicillin  [ ] Codeine  [ ] Erythromycin

              [ ] Sulfa [ ] Anesthetic  [ ] None   Other: _______________________________

What MEDICINES do you take? [ ] None ____________________________________

Have you ever been in the HOSPITAL?  [ ] Yes [ ] No

If so, for what? ________________________________________________________

Do you HAVE, or have you ever HAD any of the following?  check [x] =yes

Female:  Are you PREGNANT?  [ ] Yes [ ] No    1st  2nd  3rd  Trimester

DENTAL INFORMATION

Reason for Dental Visit: _________________________________________________

Last Dental Visit: ___/___/___     Last Full Mouth X-rays: ___/___/___

How often do you Brush your teeth? __________________  Floss? ________________

Do you HAVE, or have you ever HAD any of the following?  check [x]=yes  

Best Appointment Times:   [ ] AM [ ] Lunch [ ] PM,  Mon  Tue  Wed  Thur  Fri

CONSENT  for  TREATMENT

I authorize the Doctor and Staff to perform any and all forms of Xray, Treatment, Medication, and Therapy that may be indicated or deemed necessary or advisable via the Diagnosis of the Patient.  I understand that Anesthetic Agents contain a certain risk.  I understand that I am Fully Responsible for all Dental Fees whether I have Insurance or not.

I hereby Assign All Insurance Benefits to the Doctor. 

Signed:___________________________   Relationship:_________________          __/__/__

Updated:             Initials:        __/__/__             Initials:        __/__/__             Initials:        __/__/__