Patient Information
Welcome!
Please enter your Patient Information before your visit.
Name: *
Your answer
Birthdate: *
MM
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DD
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YYYY
Email:
Your answer
Home address: *
Your answer
Phone Number:
Your answer
Do you have insurance?
Name of insured and relationship to patient:
Your answer
Birthdate/SSN of Insured:
MM
/
DD
/
YYYY
Employer Name:
Your answer
Employer Address:
Your answer
Group #/Policy ID:
Your answer
Please check the box if you have (or have had) any of the following:
Women Only: Please check the box if the information applies to you.
Allergies: Check the box if you are allergic or have had allergic reactions to the following.
Medication/substances: Please check the box if you use the following.
Please list any medications you take:
Your answer
Dental History: Please check the box if the following applies to you.
Date of Last Dental Exam:
MM
/
DD
/
YYYY
If you have had any orthodontic treatment, please explain:
Your answer
If you wear dentures or partials, please input the date of placement:
MM
/
DD
/
YYYY
Do you like your smile?
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