Mr.

Mrs

MS

Miss

Dr.

First name

Last name

Date of birth:

Phone

Email*

Preferred contact method

Emergency contact person

Emergency contact number

Name of primary insurance policy holder*

Employer:

Date of Birth:

Name of insurance company

I.D or certificate number

Name of secondary insurance policy holder:

Employer:

Date of birth:

Name of insurance company:

I.D or certificate number:

Group policy or plan number:

All fees or balances not covered by your dental insurance policy will be payable at time of visit. You must provide us with all insurance information. We do not have access to your private insurance policy information unless provided to us.

I understand, certify that I (or my dependent) have insurance coverage and assign directly to Eagle Family Dentistry all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Eagle Family Dentistry to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

New choice

Website

Internet

Yellow pages

Referral

Family member or friend:

Other:

Sensitivity

Grinding or clenching teeth

Tooth pain or discomfort when chewing

Bleeding, swollen or irritated gums

Headaches, earaches, or neck pain

Loose or shifting teeth

Jaw joint pain (clicking or cracking)

Bad breath or taste in the mouth

Broken teeth or fillings

When was your last dental visit?*

What was done at last visit?*

When having dental treatment, do you require sedation?*

Yes

No

Sometimes

Do you smoke or chew tobacco?*

Yes

No

If "Yes' for how long?

Make your teeth whiter/brighter

Make your teeth straighter

Close Spaces

Replace fillings

Repair chipped teeth

Replace missing teeth

Replace crowns

Have a smile makeover

Other

If you chose other above, please specify:

What is the most important thing to you in regards to visiting the dentist?*

AIDS

Rheumatic Fever

HIV Positive

Excessive Bleeding

Arthritis

Stomach Problems

Liver Disease

Heart Conditions

Blood Disorders

Tuberculosis

Pregnant

Hepatitis A/B

Diabetes

Allergies

Seizures

Jaundice

Fainting

Artificial joints

Stroke

Low blood pressure

Heart murmur

Cancer

Ulcers

Respiratory problems

High blood pressure

Emphysema

Anemia

Snoring or sleep apnea

Kidney disease

Glaucoma

Asthma

Thyroid disease

Pacemaker

Heart disease

Chemotherapy

Other

If you picked other above, please list here

Aspirin

Sulpha drugs

Codeine

Local anaesthetic

Penicillin

Latex

Other

Do you have any joint replacements?*

Yes

No

Do you require premedication for dental work?*

Yes

No

Are you currently under a physician’s care?*

Yes

No

If you answered yes to the prior question, what are you under care for?

Physician’s name and phone number*

Pharmacy's name and phone number*

I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical questions. I authorize Eagle Family Dentistry to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care.

Number

New Patients