New Patient Information Form 1Patient Information2Insurance Information3Phone Numbers4Dental History5Health History6Medications, Supplements, Remedies & Allergies7Physicians Todays Date MM slash DD slash YYYY Patient Name* First Last Status*MarriedWidowedSingleMinorSeparatedDivorcedParteneredPreferred Name Email Birth Date* MM slash DD slash YYYY Age Sex* Male Female SSN* Cell Phone*Work PhoneHome PhoneBest way to contact you for appointment reminders:* Email Text Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation Employer Employer's PhoneEmployer's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouse's Name First Last Spouse's Birth Date MM slash DD slash YYYY Spouse's SS# Spouse's Phone NumberSpouse's Employer Whom may we thank for referring you? Who is the subscriber for your dental insurance?* Subscriber's Name* First Last SS# Relationship to Patient Insurance Co* ID #* Group # Birth Date* MM slash DD slash YYYY Relationship to Patient Insurance Co Group # Is patient covered by additional insurance? Yes No Assignment and Release I Certify that I, and/or my dependent(s), have insurance coverage with the following Insurance Company(ies) and assign directly to Cornerstone Dental all insurance benefits, of any, otherwise payable to me for services rendered. I Understand that I am financially responsible for all charges whetehr or not paid by insurance. I authorize the use of my signature on all insurance submissions.Name of Insurance Company(ies) I give my permission to Cornorstone Dental and its affiliates to use and disclose my health care information to the Insurance Company (ies) I so designate and their agents for the purpose of determining insurance benfits, obtaining payment for services, or the benefits payable for related services.Name of Patient, Parent, Guardian or Personal Representative First Last Date MM slash DD slash YYYY Relationship to Patient Signature* Home Phone*Work PhoneExtension Cell Phone*Spouse's Work PhoneBest time and place to reach you In case of emergency, Contact (Specify someone who does not live in your household)Name* First Last Relationship* Home Phone*Work Phone Reason for today's visitFormer Dentist City / State Date of last dental visit MM slash DD slash YYYY Date of last dental X-rays MM slash DD slash YYYY Place a mark on 'Yes' or "No' to indicate if you had any of the following:Bad Breath* Yes No Bleeding gums* Yes No Blisters on lips or mouth* Yes No Are you happy with your smile?* Yes No Burning sensation on tongue* Yes No Chew on one side of mouth* Yes No Cigarette, pipe or cigar smoking* Yes No clicking or popping jaw* Yes No Dry mouth* Yes No Fingernail biting* Yes No Food collection between the teeth* Yes No Foreign objects* Yes No Grinding teeth* Yes No Gums swollen or tender* Yes No Jaw pain or tiredness* Yes No Lip or cheek biting* Yes No Loose teeth or broken fillings* Yes No Mouth breathing* Yes No Mouth pain, brushing* Yes No Orthodontic treatment* Yes No Pain around ear* Yes No Periodontal treatment* Yes No Sensitivity to cold* Yes No Sensitivity to heat* Yes No Sensitivity to sweets* Yes No Sensitivity when biting* Yes No Sores or growths in your mouth* Yes No How often do you floss?* How often do you brush?* Do you have any dental concerns you would like to discuss?* Yes No Primary Care Physician's Name Primary Care Physician's Phone NumberDate of last visit MM slash DD slash YYYY Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine) Yes No Place a mark on 'Yes' or "No' to indicate if you had any of the following:AIDS / HIV* Yes No Anemia* Yes No Arthritis, Rheumatism* Yes No Artificial Heart Valves* Yes No Artificial Joints* Yes No Asthma* Yes No Back Problems* Yes No Bleeding abnormally, with extractions or surgery* Yes No Blood Disease* Yes No Cancer* Yes No Chemical Dependency* Yes No Chemotheraphy* Yes No Circulatory Problems* Yes No Congenial heart Lesions* Yes No Cortisone treatments* Yes No Cough, persistent or bloody* Yes No Diabetes* Yes No Emphysema* Yes No Epilepsy* Yes No Fainting or dizziness* Yes No Glaucoma* Yes No Headaches* Yes No Heart Murmur* Yes No Heart Problems* Yes No Hepatitis* Yes No Hepatitis Type* Herpes* Yes No High blood pressure* Yes No Jaundice* Yes No Jaw pain* Yes No Kidney Disease* Yes No Liver Disease* Yes No Low blood pressure* Yes No Mitral valve prolapse* Yes No Nervous problems* Yes No Pacemaker* Yes No Psychiatric care* Yes No Radiation treatment* Yes No Respiratory Disease* Yes No Rheumatic fever* Yes No Scarlet fever* Yes No Shortness of breath* Yes No Sinus trouble* Yes No Skin Rash* Yes No Special Diet* Yes No Stroke* Yes No Swollen feet or Ankles* Yes No Swollen neck glands* Yes No Thyroid problems* Yes No Tonsilitis* Yes No Tuberculosis* Yes No Tumor or growth on head or neck* Yes No Ulcer* Yes No Venereal disease* Yes No Weight loss, unexplained* Yes No Have you ever been told you need to take pre-medication before a dental procedure?* Yes No Do you wear contact lenses?* Yes No WomenAre you pregnant?* Yes No Due Date MM slash DD slash YYYY Are you nursing?* Yes No Taking birth control pills?* Yes No Are you currently taking any medications?* Yes No Please list any medications, supplements or homeopathic remedies you are currently taking and the correlating diagnosis. If none, please type "none."*Pharmacy Name PhoneAllergiesAllergies* Aspirin Barbiturate (Sleeping pills) Codeine Iodine Latex Local Anesthetic Penicillin Sulfa Other None Other Please list names, location and phone numbers of all your attending doctors.1st Dr Name Location Phone2nd Doctor Name Location PhonePlease list any surgeries or medical conditions you have or have ever had.We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly mutual understanding between provider and patient. Our policy requires payment in full at the time services are rendered, unless other formal written arrangements have been made with our office management. If the account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for all legal fees, collection agency fees, interest charges and any other expenses incurred for collection of the debt. I authorize the staff of Cornerstone Dental to perform any necessary services needed during diagnosis and treatment. Filing of insurance claims is a courtesy we provide to our patients. I authorize Cornerstone Dental to release any information required to process my insurance claims. I understand the above information and state this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to this information I provided.Print name of Patient, Parent, Guardian or Personal Representative* First Last Date* MM slash DD slash YYYY Signature*
