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New Patient Form


    Patient Information

    Today's Date: ← Click Here

    Name:

    Last:

    First:

    MI:

    Preferred Name:

    Address:

    Street:

    City:

    State:

    ZIP Code :

    Sex: MaleFemale

    Birth Date: ← Click Here

    Age:

    Social Security #:

    Home Phone:

    Cell Phone:

    Work Phone:

    Email:

    Marital Status: SingleMarriedWidowedSeparatedDivorced

    Occupation:

    Employer:

    Employer Phone:

    Driver’s License Number:

    Driver’s License State:

    Spouse Name:

    Spouse Phone:

    Spouse Occupation:

    Parent Name (if patient is a minor):

    Parent's Email:

    Parent Phone #:



    Emergency Contact

    Name:

    Last:

    First:

    Relationship:

    Home Phone:

    * Cell Phone:

    Work Phone:

    Email:



    Responsible Party Information

    Name:

    Last:

    First:

    Relationship to Patient:

    Sex: MaleFemale

    Birth Date: ← Click Here

    Age:

    Social Security #:

    Address:

    Street:

    City:

    State:

    Zip Code:

    Home Phone:

    Cell Phone:

    Work Phone:

    Email:

    Occupation:

    Employer:

    Employer Phone:



    Insurance Subscriber Information

    Subscriber Name:

    Last:

    First:

    Relationship:

    Sex: MaleFemale

    Birth Date: ← Click Here

    Social Security #:

    Occupation:

    Home Phone:

    Cell Phone:

    Work Phone:

    Email:

    Insurance Company:

    Insurance Phone:

    Insurance Claims Address:

    Street:

    City:

    State:

    Zip Code:

    Group #:

    Subscriber #:

    Contract #:

    Employer:

    Employer Phone:

    Effective Date: ← Click Here

    Name of any other dependants covered under this plan:



    Referral Information

    Full Name and relationship:

    Whom may we thank for referring you? www.infinityda.comYellow PagesSearch EngineYelpFacebookAngie’s ListOther website

    Other website (please specify):



    Dental History

    What is the primary reason for your visit to our practice today?

    Are you currently in dental discomfort today? YesNo

    If yes, for how long:

    How long have you been in discomfort?:

    What is the location of the discomfort? Upper RightUpper LeftLower LeftLower Right

    The pain is: SharpDull/Aching

    Other:

    Has the pain worsened since it began? YesNo

    Have you taken any medication to relieve the pain? YesNo

    if Yes, Name of Medication and dose taken:

    Time of last dose: ← Click Here

    Did this help?

    Did the pain keep you awake or wake you up from sleeping? YesNo

    Have you sought dental treatment for this problem in the past? YesNo

    If yes, when? ← Click Here

    What was the suggested course of treatment?

    Do you require antibiotics before dental treatment? YesNo

    If yes, which one have you taken in the past:

    Previous Dentist’s Name:

    Address:

    Phone #:

    Email:

    Date of last dental evaluation: ← Click Here

    Date of last x-rays: ← Click Here

    Date of last professional cleaning: ← Click Here

    How often to do you brush?

    How often do you floss?

    Your current dental health is: GoodFairPoorUnknown

    Have you had a bad experience in the dental office? YesNo

    If yes, tell us your experience:

    Have you ever had problems with or have been treated for any of the following dental conditions:

    Bleeding Gums: CurrentPastNever

    Bad Breath: CurrentPastNever

    Bad Taste/Odor: CurrentPastNever

    Cold Sores: CurrentPastNever

    Periodontal Disease: CurrentPastNever

    Periodontal Treatment: CurrentPastNever

    Deep Cleaning/Scaling: CurrentPastNever

    Sensitivity to Hot: CurrentPastNever

    Sensitivity to Cold: CurrentPastNever

    Sensitivity to Sweets: CurrentPastNever

    Sensitivity to Biting: CurrentPastNever

    Food Collection: CurrentPastNever

    Loose Teeth: CurrentPastNever

    Broken Fillings: CurrentPastNever

    Grinding of the teeth: CurrentPastNever

    Clenching of the teeth: CurrentPastNever

    Clicking/Popping of the jaw: CurrentPastNever

    Oral Cancer/Biopsy: CurrentPastNever

    Wisdom teeth extraction(s): CurrentPastNever

    Tooth brush abrasion: CurrentPastNever

    Recession of the gums: CurrentPastNever



    Medical History

    Physician’s Name:

    Phone #:

    Date of last visit: ← Click Here

    Address:

    Email:

    Have you had any serious illnesses or operation? YesNo

    If yes, please specify:

    Are you currently under the care of a physician? YesNo

    If yes, please specify:

    Have you ever taken Fen-Phen or Redux and developed a heart murmur? YesNo

    If yes, please specify:

    Women Only:

    Are you Pregnant: YesNo

    Due Date: ← Click Here

    Nursing: YesNo

    Birth Control: YesNo

    Please specify:

    Have you ever had, been treated, or are currently being treated for any of the following diseases or medical problems?

    Alcohol/Drug Abuse: YesNo

    Anaphylaxis: YesNo

    Anemia: YesNo

    Artificial Joints: YesNo

    Artificial Heart Valve: YesNo

    Asthma: YesNo

    Allergy Prone: YesNo

    Back problems: YesNo

    Bleeding problems: YesNo

    Blood Disease: YesNo

    Blood Transfusion: YesNo

    Cancer: YesNo

    Chemical dependency: YesNo

    Chemotherapy: YesNo

    Cirulatory problems: YesNo

    Congenital Heart Defect: YesNo

    Cortisone treatments: YesNo

    Cough, persistent: YesNo

    Coughing up blood: YesNo

    Diabetes: YesNo

    Difficulty breathing: YesNo

    Dry Mouth: YesNo

    Emphysema: YesNo

    Epilepsy: YesNo

    Fainting/Dizzy spells: YesNo

    Food allergies: YesNo

    Frequent headaches: YesNo

    Glaucoma: YesNo

    GERD: YesNo

    Heart Attack: YesNo

    Heart murmur: YesNo

    Heart surgery: YesNo

    Hemophilia: YesNo

    Hepatitis A, B, C, D, E: YesNo

    Herpes/Fever Blister: YesNo

    High Blood Pressure: YesNo

    High Cholesterol: YesNo

    HIV/ARC/AIDS: YesNo

    Jaw Pain: YesNo

    Kidney disease: YesNo

    Latex Allergy: YesNo

    Liver disease: YesNo

    Low blood pressure: YesNo

    Metal allergy: YesNo

    Migraine Headaches: YesNo

    Mitral Valve Prolapse: YesNo

    Nervous Problems: YesNo

    Pacemaker: YesNo

    Psychiatric Care: YesNo

    Radiation Therapy: YesNo

    Rapid weight gain/loss: YesNo

    Recreational Drugs: YesNo

    Respiratory disease: YesNo

    Rheumatic/Scarlet Fever: YesNo

    Reflux: YesNo

    Seizures: YesNo

    Shingles: YesNo

    Shortness of breath: YesNo

    Sickle Cell Trait/Disease: YesNo

    Sinus Problems: YesNo

    Spina Bifida: YesNo

    Stroke: YesNo

    STD: YesNo

    Pins, Plates, or other metal surgical implants: YesNo

    Swelling of feet/ankles: YesNo

    Thyroid Disease: YesNo

    Tobacco Habit: YesNo

    Tonsillitis: YesNo

    Tuberculosis: YesNo

    Ulcer/Colitis: YesNo

    Venereal Disease: YesNo

    Other:

    Please list all medications you are currently taking:

    Do you have any drug allergies:

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