1 Patient Information Date SS/HIC/Patient ID # Name Address City ...

Patient Information
SS/HIC/Patient ID #
Name
Date
DENTAL INSURANCE
Who is responsible party for this account?
Address
City
State
E-mail
Home Phone
Work Phone
Occupation/Employer
Employer Address
Zip
Cell Phone
ext
Relationship to Patient
Insurance Company
Group # Account #
Subscriber’s Name
Birth-date
SS#
Additional Insurance coverage/Company?
Relationship to Patient
Insurance Company
Group # Account #
SS#/SIN
DL#
Sex: M F Age
Birth-date:
Married Widow ed Single Separated
Divorced Minor Partnered for ______ yrs
Who may w e thank for referring you?
If Minor, Responsible Party Parent/Guardian Information?
Mother Father Legal Guardian
Name
Subscriber’s Name
Birth-date
SS#
Assignment and Release
I certif y that I, and/or my dependents (s), hav e insurance cov erage with
and assign directly to New Town Dental
Arts
(Name of insurance company )
All insurance benef its, if any , otherwise pay able to me f or serv ices rendered. I
understand that I am f inancially responsible f or all charges whether or not paid by
insurance. I authorize the use of my signature on all insurance submissions.
New Town Dental Arts may use my health care inf ormation and may disclose such
inf ormation to the abov e-named insurance company (ies) and their agents f or the
purpose of obtaining pay ment f or serv ices and determining insurance benef its or the
benef its pay able f or related serv ices. This consent will be v alid so long as I am a
patient at New Town Dental Arts.
Address
City
State
E-mail
Home Phone
Work Phone
Employer/Occupation
Zip
Cell Phone
ext
Signature of Patient, Parent or Guardian or Personal Representativ e
Please print Signature of Patient, Parent or Guardian or Personal Representativ e
Emergency Contact (someone who does not live in your
household)
Name
Employer Address
SS#/SIN
DL #
Sex: M F Age
Birth-date:
Dental History
Reason for today’s visit
Former Dentist
Date of Last dental visit
Date of last x-Rays/Dental Image
Relationship
Home Phone
Cell Phone
Work Phone
Child’s Physician
Phone
Fingernail biting YES NO Sores or grow ths in your mouth
Food collection betw een teethYES Previous Hospitalizations/surgeries/Serious NO
YES NO Illnesses?
Foreign objects YES NO Water Fluoridated?* YES NO
Grinding/Clinching of teeth YES Child Thumb sucking?
NO
YES NO
Gums sw ollen YES NO Child lip biting? YES NO
Jaw pain or tiredness
YES Child Chew ing hard objects? YES NO
NO
Child Grinding Teeth?
Place a check on “yes or no” if you have any of the Lip or cheek biting YES NO
YES NO
follow ing:
Loose teeth or broken fillings YES NO Child Clench Jaw s? YES NO
Bad breath
YES Mouth breathing YES NO Flossing frequency?
NO
Mouth pain, brushing
YES Brushing frequency?
Bleeding gums YES NO
NO
Blisters on lips or mouth YES NO Orthodontic treatment (braces) YES If minor, has your child had difficulty with
Burning sensation on tongue YES NO
NO
previous dental exams?
Chew on one side of mouth YES NO Pain around ear YES NO If yes, please explain
Cigarette, pipe, or cigar smoking YES Periodontal treatment (Gums) YES
NO
NO
Clicking or popping jaw YES NO Sensitivity to cold YES NO
Drink Bottled Water YES NO Sensitivity to heat YES NO *Adult bottle w ater use?
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Dry mouth
YES Sensitivity to sw eets
YES
NO
NO
4939 Courthouse Street — Williamsburg, Virginia
Sensitivity
23188
w hen
—
biting
757/259-0741
YES
· Fax
NO
757/259-0718 www.newtowndentalarts.net
Smokeless Tobacco
YES

Health History
Physician’s Name
Date of Last visit
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 have had any of the
following:
AIDS/HIV
YES NO GLAUCOMA YES NO SPECIAL DIET YES NO
ARTHRITIS, RHEUMATISM YES HANDICAPS OR
STOMACH PROBLEMS YES
NO
DISABILITIES YES NO
NO
ARTIFICIAL HEART VALVESYES HEADACHES YES NO STROKE
YES
NO
NO
HEART MURMUR
YES
ARTIFICIAL JOINTS YES NO
NO
SWOLLEN FEET
ASTHMA
YES NO HEART PROBLEMS YES NO
OR ANKLES YES NO
BACK PROBLEMS
YES HEPATITIS TYPE ____ YES SWOLLEN NECK GLANDS YES
NO
NO
NO
BLEEDING ABNORMALLY, WITH
HERPES
YES THYROID PROBLEMS YES NO
NO
TONSILLITIS YES NO
EXTRACTIONS OR SURGERYYES
HIGH BLOOD PRESSURE YES TUBERCULOSIS
YES
NO
NO
NO
BLOOD DISEASE
YES JAUNDICE YES NO TUMOR/GROWTH ON HEAD
NO
JAW PAIN YES NO
OR NECK YES NO
CANCER
YES KIDNEY DISEASE
YES ULCER YES NO
NO
NO
VENEREAL DISEASE YES NO
CHEMICAL DEPENDENCY YES LIVER DISEASE
YES WEIGHT LOSS,
NO
NO
UNEXPLAINED YES NO
CHEMOTHERAPY
YES LOW BLOOD PRESSURE YES
Do you wear contact lenses?
NO
NO
YES NO
CIRCULATORY PROBLEM YES
MITRAL VALVE PROLAPSEYES
Have you ever taken
NO
NO
NERVOUS PROBLEMS
BISPHOSPHONATES
YES NO
CONGENITAL HEART
PACEMAKER
or any Bone Building drug?
YES NO
LESIONS
YES
YES NO
PSYCHIATRIC CARE YES NO
NO
RADIATION TREATMENT YES
CONGENITAL HEART
If yes, please list:
NO
DEFECT
YES RESPIRATORY DISEASE YES
NO
NO
WOMEN: CONVULSIONS
YES RHEUMATIC FEVER YES NO
Are you pregnant? YES NO Due Date Are you nursing? YES NO
Taking birth NO control pills? YES NO SCARLET FEVER
YES
CORTISONE TREATMENTS YES
NO
MEDICATIONS: NO
SHORTESS OF BREATH YES
NO
List COUGH, any medications PERSISTENT you are currently taking and the correlating diagnosis:
SINUS TROUBLE
YES
OR BLOODY YES NO
NO
DIABETES
YES NO
SKIN RASH YES NO
EMPHYSEMA YES NO
EPILEPSY
YES
NO
Pharmacy FAINTING Name OR DIZZINESS YES
Phone ( )
ALLERGIES: NO
Aspirin Codeine Iodine Latex Local Anesthetic Sulfa
Barbiturates (sleeping Pills) Penicillin Other
Authorization and Release. To the best of my knowledge, the questions on this f orm hav e been accurately answered. I understand that prov iding incorrect inf ormation can be
dangerous to my self and or my child’s health. It is my responsibility to inf orm the dental of f ice of any changes in my or my child’s medical status. I also authorize the dental staf f to
perf orm the necessary dental serv ices my child may need. I also authorize the dentist to release any inf ormation including the diagnosis and the records of treatment or examination
rendered to my self or my child during the period of such care to third party pay ers and /or other health practitioners. I authorize and request my insurance company to pay directly to
the Dentist or Dentist’s group insurance benef its other wise pay able to me. I understand that my insurance carrier may pay less than the actual bill f or serv ices. I agree to be
responsible f or pay ment of all serv ices rendered on my behalf or my dependents.
Signature of patient or responsible party if a minor
Date
Signature of Dentist/Doctor’s Review
Date
New Town Dental Arts 4939 Courthouse Street — Williamsburg, Virginia 23188 — 757/259-0741 · Fax 757/259-0718
www.newtowndentalarts.net
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