N e w P a tien t F o r m
Today’s Date:
Patient Information
Anthony Gardiner
D.D.S
Referred By:
Sex:
Birth date:
Height:
Weight:
Martial Status:
Spouse’s Name:
Spouse’s Number:
Name:
Telephone:
Alternative Phone:
Relationship:
Name:
Address:
City:
Zip Code:
Telephone:
Alternative Phone:
Sex:
Social Security:
Employer:
Employer Number:
Occupation:
Individual Responsible for Billing ( leave blank if the same as above )
Patient’s Emergency Contact
(Please Select Applicable Answer)
1.) Your general health is?
M e d i c a l H i s t o r y
Name:
Telephone:
Medical Physician
2.) Is a doctor currently treating you?
3.) Any health changes in the past year?
5.) Have you had a blood transfusion?
6.) Have you had a facial or jaw injury?6.) Have you had a facial or jaw injury?
7.) Have you had treatment for a tumor?
8.) Are you ever short of breath?
9.) Do you ankles ever swell?
10.) Could you be pregnant?
11.) Have you ever used diet drugs?
12.) Do you use tobacco products?
13.) Do you need a dental Premed?
14.) Are you or have you taken bone
density medictation?
15.) Are you taking blood thinning
medicaton?
How often?
Type?
Allergies:
I n s u r a n c e I n f o r m a t i o n
A U T H ORIZ A TIO N
Have you had any of the following?
CONDITION ONSET DATE
AIDS
Anemia
Arthritis
Bleeding Disorder
Cancer
Hearing Loss
Heart Attack
Heart Murmur
List Current Medications:
Hepatitis
High Blood Pressure
(if so, what type?)
(if so, what type?)
CONDITION ONSET DATE
HIV+
Implant
Kidney
Seizures
Stroke
Tuberculosis
Ulcer
Stents
(if so, what type?)
Psychiatric Disorder
Thyroid Disorder
Reactions:
Do you have dental insurance?Do you have dental insurance?
Primary Insurance Name:
Employer Name:
Employee Name:
ID#:
Employee Birth date:
Group or Policy Number:
SIGNATURE
DATE
Group or Policy Number:
Secondary Insurance Name:
Employer Name:
Employee Name:
ID#:
Employee Birth date:
Would you like to set-up payment arrangements?
understand any amount not covered by insurance or if I do not have insurance covereage is my responsibility to pay the charged amount.
The above dental and medical histories, the personal and insurance information are all correct to the best of my knowledge. I grant the
right to the dentist to release my dental/medical histories and personal information to third party payers and/or other health professionals.
N o t i c e o f P r i v a c y P r a c t i c es - A c k n o w l e d g eme n t
PRINTED PATIENT NAME DATE TIME
PATIENT’S SIGNATURE
SIGNING ON BEHALF OF PATIENT
RELATIONSHIP TO PATIENT
We keep record of the dental/health care services we provide to you. You may ask to see and copy that record. You may ask to correct that
record. We will not disclose your record to others unless you direct us to do so, we refer you to another provider or unless the law authorizes
Our Notice of Privacy Practices describes in detail how your health information may be used and disclosed and how you can access your
information.
By my signature below I acknowledge receipt of the Notice of Privacy Practices.
Male Female
Name:
Address:
City:
Zip Code:
Telephone:
Alternative Phone:
Social Security:
Employer: Employer
Telephone:
Occupation:
Male Female
4.) Have you been hospitalized or had
surgery in the last 5 years?
reason?
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Type?
click to sign
signature
click to edit
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click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
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