1Step 1 of 4 : Patient Info2Step 2 of 4 : Dental Insurance and Authorization3Step 3 of 4 : Dental and Medical History4Step 4 of 4 : The remainder of the form Date MM slash DD slash YYYY Do you have any allergies? If so, list herePatient InformationPatient's Name Date MM slash DD slash YYYY Sex Address Cell PhonePatient's School Patient's Dentist Patient's Physician Hobbies Parent's or Guardian Name (if Patient is minor) Responsible Party Information (for patients under the age of 18) Responsible PersonName Marital Status Address Email Home PhoneCell PhoneWork PhoneBirth Date MM slash DD slash YYYY Relationship to Patient Employer Occupation No. Years Employed SpouseSpouse's Name Relationship to Patient Employer No. Years Employed Birth Date MM slash DD slash YYYY Daytime Phone Dental Insurance InformationInsured's Name Insurance Company Group No. Insured's Employer Insured's Birth Date MM slash DD slash YYYY Insured's ID/Policy Number Insured's Phone №Do you have dual coverage? Yes No Insured's Name Insurance Company Group No. Insured's Co. Address Insured's Employer Insured's Birth Date MM slash DD slash YYYY I authorize the following 1) The release of dental records or other information to process any claims filed by this office for services rendered. 2) Payment of dental benefints to Dr. Paul McAllister. 3) This copy of my signature to be sent with my insurance claims.Primary SignatureSecondary Signature Dental HistoryDo you have any of the following? Any family members who have had orthodontics. Teeth sensitive to hot / cold. Injuries to your teeth, face, jaw and mouth. Bleeding gums, bad taste in mouth. Root canals, crowns or bridges. Suck your thumb and / or fingers. Any clicking, popping or pain of the jaw, joints (TMJ). Any missing teeth or extra teeth. Treatment with Speech Therapy. Date of most recent dental exam MM slash DD slash YYYY How often do you brush your teeth? How often do you floss? What type of toothbrush do you use? Manual Battery operated Medical HistoryDo you have any of the following? Heart Disease Heart Murmur Rheumatic Fever High Blood Pressure Diabetes Blood Disorder AIDS of Immune Suppresive Disorder Hepatitis A, B, C or D Allergy to Latex Sleep apnea / snoring Tonsil or Adenoid Problems Tendency to be a mouth breather Epilepsy Tuberculosis or lung disease Allergies: Allergies: Do any conditions exist other than those mentioned above? Is the patient taking medications and what are they? Is the patient taking any preventive osteoporosis medications? If so, which one? What is the main thing you would like to find out by coming to see Dr. McAllister and what would you like to change about your smile? Who may we thank for referring you to our office? How did you hear about our office? Referring Doctor Friend Insurance website Advertisement Orthodontic website Our sign Telephone book Co-worker I prefer to be contacted during the day by:Cell PhoneOffice PhoneHome PhoneEmail: Other: May we use patient's photo for educational and promotional purposes? Yes No NameThis field is for validation purposes and should be left unchanged.
