Heathbrook Dental Patient Form

Email *

Preferred Name

Title

First Name *

Last Name *

Referred By

Phone *

Address

Street Address

City

State

Country

Postal Code

Date Of Birth

Sex

Marital Status

Preferred Pharmacy

Preferred Pharmacy City/State/Zip

Preferred Pharmacy Phone

Employment Status *

College Student Status *

Employer

Employer Address

Employer Phone

School Name

School Address

Emergency Contact Relationship

Emergency Contact Home Phone

Emergency Contact Cell Phone

Emergency Contact Name

Dental Insurance Information

Has Dental Insurance?

Primary Insurance Company

Primary Insurance Address

Primary Insurance City/State/Zip

Primary Insurance ID #

Primary Insurance Group #

Has Secondary Insurance?

Secondary Insurance City/State/Zip

Secondary Insurance ID #

Secondary Insurance Company

Secondary Insurance Group #

Secondary Insurance Address

Dental Information

Do Your Gums Bleed During Brushing/Flossing?

Yes

Don't Know

Are your teeth sensitive to cold, hot, sweets, or pressure?

Yes

Don't Know

Is your mouth dry?

Have you ever had any periodontal(gum) treatment?

Have you ever had orthodontic(braces) treatments?

Have you ever hade any problems with previous dental treatment

Do you drink bottled/filtered water

Is your home water supply fluoridated?

How often do you drink bottled/filtered water?

Are you currently experiencing any dental pain or discomfort

Do you have earaches or neck pain?

Do you have any clicking, popping or discomfort in the jaw?.

Do you brux or grind your teeth?

Do you have sores or ulcers in your mouth?

Do you wear dentures or partials?

Have you ever had a serious injury to your head or mouth?

Last Dental Exam Date

Last Dental Cleaning Date

Dental X-ray

What is the reason for your dental visit today?

How do you feel about your smile?

Are you currently under a physicians care?

Reason for being under physicians care:

Physician Phone

Physician Name

Have you recently been hospitalized or had a major operation?

Hospitalization/major operation explaination

Are you taking any medications, pills, or drugs?

Yes

Medications List

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

List any that apply:

Women:

Women: Are you...

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Allergies

List any other allergies

Controlled Substances

List controlled substances

Comments:

Feel Free to share any addition dental or medical information here.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent or Guardian

Clear