PPFDdesk New Patient Form (Adult 18+)

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Welcome to Paw Paw Family Dentistry! Thank you for completing each question to the best of your ability.

Email *

32800 E Red Arrow Highway

Paw Paw, MI 49079

269-657-4001

Today's Date: *

YYYY

Your Last Name: *

Your First Name and Middle Initial: *

Nickname/Preferred Name: *

Birthdate: *

YYYY

Gender: *

Male

Female

Prefer not to say

Street Address or PO Box: *

City: *

State: *

Zip: *

Home Phone and/or Cell Phone: *

Email (confirm the email address entered above on the line below): *

Social Security Number: *

Driver's License Number: *

Marital Status: *

Single

Married

Divorced

Widowed

Separated

Prefer not to say

Spouse's name if applicable:

Spouse's phone number:

Other family members who have seen us:

Employer:

Employer Address:

Employer Phone Number:

Emergency Contact's Name and Phone Number: *

Who is the one responsible for your account? *

I understand that payment is due at time of service: *

YES

We do NOT bill to medical, ortho, workers' comp, auto, or lawsuits (i.e. restaurants, playground, etc.) *

YES, I understand that PPFD does not bill any insurances other than DENTAL.

Required

Insurance Company Name: (Type N/A or "none" if not applicable.) *

Insurance Company Phone Number:

Insurance Company Group# (Plan, Local, or Policy#):

Insurance Company Address: (Type N/A or "none" if not applicable) *

Insured's Name:

ID# or SS# of the INSURED:

Insured's Birthdate:

YYYY

Your relation to the INSURED:

Secondary Insurance Company (if applicable):

Secondary Insurance Phone Number:

Secondary Insurance Group Number:

Secondary Insurance Address:

What brings you to our practice? *

I am a new patient interested in routine dental care.

I am a new patient with mouth concerns/discomfort.

Required

Check each box if YES: *

I am currently in pain

I require an antibiotic before treatment

I have experienced problems in the past associated with dental work

I have experienced jaw pain or discomfort in the past

My current dental health is GOOD

My current dental health is FAIR

My current dental health is POOR

I floss every day

I brush every day

I would like fresher breath

I would like whiter teeth

Sometimes my gums bleed

Sometimes my gums itch

I have periodontal disease (now or in the past)

Sometimes my teeth wiggle and move

My teeth are sensitive to hot and/or cold

I have one or more of my wisdom teeth

None of the above

Required

Why did you leave your previous dentist?

What did you like most and least about any dentist you have seen?

Do you have a personal PHYSICIAN? *

Yes

Physician's Name:

Date of last visit:

YYYY

Physician's Phone Number:

Check all that apply as a YES: *

I am currently under the care of a physician

My overall health is GOOD

My overall health is FAIR

My overall health is POOR

I have been vaccinated for Covid-19

I smoke or use tobacco in any form

I have been told that I snore or hold my breath while sleeping

I have been told that I wake up gasping for breath

I have taken FOSAMAX or another BISPHOSPHONATE

Required

Check the box if you are allergic to any of the following: *

Aspirin

Barbiturates

Codeine

Dental Anesthetics

Erythromycin

Jewelry/Metals

Latex

Penicillin

Sedatives

Sulfa Drugs

Tetracycline

None of the above

Other:

Required

For WOMEN:

I currently take birth control pills

I am currently pregnant

I am currently nursing

Check the box if you are taking any of the following: *

Acetaminophen

Antibiotics

Antihistamines

Aspirin

Blood Thinners

Blood Pressure Medication

Cold Remedies

Digitalis/Heart Medication

Insulin/Diabetes Drugs

Nitroglycerin

Recreational Drugs

Steroids/Cortisone

Thyroid Medication

None of the above

Other:

Required

Are you taking any prescription, over-the-counter drugs, herbal remedies, vitamins or minerals not listed above? If yes, please list each one: *

What pharmacy do you use and what is the phone number there? *

Do you (or have you) had any of the following: *

Abnormal Bleeding

Alcohol Abuse

Anemia

Arthritis

Artificial Bones/Joints

Artificial Valves

Asthma

Blood Transfusion

Cancer

Chemotherapy

Chicken Pox

Colitis

Congenital Heart Defect

Diabetes

Difficulty Breathing

Drug Abuse

Emphysema

Epilepsy

Fainting Spells

Fever Blisters

Glaucoma

Hay Fever

Headaches

Heart Attack

Heart Murmur

Heart Surgery

Hemophilia

Hepatitis

Herpes

High Blood Pressure

HIV/AIDS

Hospitalized for Any Reason

Kidney Problems

Liver Disease

Low Blood Pressure

Lupus

Mitral Valve Prolapse

Osteoporosis/Paget's Disease

Pacemaker

Persistent Cough

Psychiatric Treatment

Radiation Treatment

Rheumatic Fever

Scarlet Fever

Seizures

Shingles

Sickle Cell Disease

Sinus Problems

Steroid Therapy

Stroke

Thyroid Problems

Tonsillitis

Tuberculosis (TB)

Venereal Disease

None of the above

Other:

Required

I affirm that the information I have given to Paw Paw Family Dentistry is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical/health status. *

YES

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