Welcome to Our Office!

Please complete the following so that we may provide you with the safest and most comfortable, comprehensive and efficient dental care possible. This form will be printed by the receptionist upon receipt and ready for you to sign upon arrival to our dental office for your scheduled appointment time.

Patient Information Your Information: Title: Select Dr. Mr. Mrs. Ms. Miss Other First Name:   Middle Name: Last Name:   Today's Date: Residence Address:   City:   State:   Zip: Residence Phone Number:   Cell Phone/Pager Number:         Email Address: How did you hear about us? Birthdate:   Social Security Number:   TX Driver's License Number: Employer:   Business Phone Number: Business Address:   City:   State:   Zip: If child, name of parents: If student, name of school: Spousal Information (If applicable): Spouse's Name:   Spouse's Employer:   Spouse's Contact Phone: Spouse's Business Address:   City:   State:   Zip: Other Contact Information: First person to contact in case of emergency:   Phone Number: Address:   City:   State:   Zip: Nearest Relative/friend not living with you:   Phone Number: Address:   City:   State:   Zip:   Account Information Person responsible for payment:   Phone: Are any of your family members patients? Yes No If Yes, please list: Will you need financial arrangements to help with the cost of your dental treatment? Yes No   Dental Insurance Please fill out the following and present an insurance card(s) and/or a completed insurance form(s) to the receptionist: Primary Dental Insurance Information: Primary Dental Insurance Company:   Group Number:   Phone Number: Address:   City:   State:   Zip: Policy Holder's Name:   Relationship of Patient to Policy Holder: Policy Holder's Birthdate:   Policy Holder's Social Security Number: Policy Holder's Employer: Secondary Dental Insurance Information: Secondary Dental Insurance Company:   Group Number:   Phone Number: Address:   City:   State:   Zip: Policy Holder's Name:   Relationship of Patient to Policy Holder: Policy Holder's Birthdate:   Policy Holder's Social Security Number: Policy Holder's Employer: The following area to be completed in the dentist's office. I authorize this office to release any information necessary to expedite insurance claims. I understand that I am financially responsible for all charges, regardless of insurance coverage. **Responsible Party Signature: ______________________________________________ **Date: _____________________ (**Please leave this area blank. There is no way to complete this section online. The receptionist will present the printed form of this document to you when you actually visit the dental office and you will sign and date this area at that time**)   Medical Health History (Confidential) Your Name:     Name of Primary Physician:   Physician's Specialty: Address:   City:   State:   Zip: Phone Number:             Please check if you have or have ever had any of the following: CARDIOVASCULAR/BLOOD   Heart Murmur   Artificial Heart Valve   Mitral Valve Prolapse   Heart Attack/Disease   Heart Failure   Heart Surgery   Heart Pacemaker   Chest Pains/Discomfort   Circulatory Problems   Rheumatic Fever   Swollen Ankles   High Blood Pressure   Low Blood Pressure   Excessive Bleeding   Bruise Easily   Anemia   Hemophilia   Leukemia   Sickle Cell Disease   Blood Transfusion NERVOUS SYSTEM   Stroke   Epilepsy/Convulsions   Fainting/Dizziness   Headaches   Numbness/Tingling   Nervous Disorders   Psychiatric Treatment RESPIRATORY   Tuberculosis   Emphysema   Asthma   Hay Fever/Allergies/Hives   Persistent Cough   Shortness of Breath   Respiratory Disease ENDOCRINE/URINARY   Diabetes   Thyroid Disease   Kidney/Bladder Trouble DIGESTIVE   Hepatitis A (Infection)   Hepatitis C (Serum)   Jaundice   Ulcers   Liver Disease   Typhoid Fever BONES/MUSCLES   Fractured Bones   Artificial Joints   Back Problems EYES/EARS/NOSE/THROAT/SKIN   Glaucoma   Ringing in Ears   Sinus Problems   Frequent Nosebleeds   Scarlet Fever   Herpes/Fever Blisters   Lupus   Measles/Mumps/Chicken Pox OTHER   AIDS/HIV Positive   Cancer   Chemotherapy/Radiation   Venereal Disease   Anorexia/Bulimia   Recent Weight Loss   Alcoholism   Drug Addiction   Surgical Implants   Other If Other, please specify: If you have marked any of the above, please briefly describe: Please list any past hospitalizations/surgeries (minor or major): Please describe any current medical treatment, impending operations, or other information that may affect your dental treatment:   Medications List medications you are currently taking: Pharmacy Name:   Phone Number:   Please list any allergies to medications: Have you ever been premedicated for your dental appointments in the past? Yes No Do you frequently drink alcohol? Yes No Do you smoke tobacco? Yes No Do you use smokeless tobacco? Yes No For Women: Are you pregnant? Yes No If so, what is the due date? Nursing? Yes No Taking Birth Control Pills? Yes No   Dental Health History (Confidential) Your Name:     Previous Dentist:   Previous Dentist's Specialty: Address:   City:   State:   Zip: Phone Number:             Date of last cleaning and exam:   Date of last full mouth x-rays: Reason for changing dentists: Have you ever had an unfavorable experience at a dental office? Yes No Briefly describe: Are you nervous about receiving dental treatment today? Yes No IMMEDIATE DENTAL CONCERN: Please check if you have experienced any of the following:   Periodontal/gum disease     How long ago?   Bleeding gums   Receding gums   Swelling of the gums   Pain or soreness in gums   Growths or swellings in mouth     How long existed?   Spaces between teeth   Drifting teeth   Food packing between teeth   Infection around teeth   High or rough fillings   Bad Breath or taste in mouth   Sensitivity to:     hot     cold     pressure     biting     chewing     tooth brushing     sweets   Clenching/grinding teeth   Jaw clicking or popping   Stiff neck muscles   Pain/soreness around eyes,ears, jaw area   Tension Headaches   Difficulty in opening/closing mouth   Difficulty in chewing/swallowing   Loose teeth How often do you brush your teeth?      How often do you floss  your teeth?   Do you use a supplemental fluoride rinse/gel at home? What kind? List any additional dental aids you use at home (i.e. electric toothbrush): Have you ever lost any teeth? Yes No From what cause? Have you ever injured your mouth/teeth in an accident? Yes No Briefly describe: Have you had any orthodontic work? Yes No How long ago? Have you had oral surgery? Yes No How long ago? Describe: Have you had periodontal treatment? Yes No How long ago? Describe: Do any of your family members wear dentures/partials? Yes No IF YOU WEAR A PARTIAL OR DENTURE, PLEASE COMPLETE THE FOLLOWING: What type of partial/denture do you have? UPPER LOWER BOTH How long have you worn a partial/denture? Are you satisfied with the appearance? Yes No Are you satisfied with the comfort? Yes No Are you satisfied with your chewing ability? Yes No Are you satisfied with your speech? Yes No

Cosmetic Dentistry

Please check any of the following cosmetic alternatives you might be interested in:   Teeth straightening   Replacing silver fillings with tooth colored fillings   Teeth whitening   Bonding   Porcelain veneers   Filling spaces   Improving the overall appearance of your smile The above information is accurate and complete to the best of my knowledge. If any change occurs in my dental and/or medical health, I will report it to this office as soon as possible. I understand that I am and/or my parent or guardian is financially responsible for all fees related to my dental treatment. **Patient Signature: ______________________________________________ **Date: _____________________ **Responsible Party Signature: ______________________________________________ **Date: _____________________ (**Please leave this area blank. There is no way to complete this section online. The receptionist will present the printed form of this document to you when you actually visit the dental office and you will sign and date this area at that time**)