1 Step 1 of 4 : Patient Info2 Step 2 of 4 : Dental Insurance and Authorization3 Step 3 of 4 : Dental and Medical History4 Step 4 of 4 : The remainder of the formDate Date Format: MM slash DD slash YYYY Do you have any allergies?If so, list herePatient InformationPatient's NameDate Date Format: MM slash DD slash YYYY SexAddressCell PhonePatient's SchoolPatient's DentistPatient's PhysicianHobbiesParent's or Guardian Name (if Patient is minor)Responsible Party Information(for patients under the age of 18)Responsible PersonNameMarital StatusAddressEmail Home PhoneCell PhoneWork PhoneBirth Date Date Format: MM slash DD slash YYYY Relationship to PatientEmployerOccupationNo. Years EmployedSpouseSpouse's NameRelationship to PatientEmployerNo. Years EmployedBirth Date Date Format: MM slash DD slash YYYY Daytime PhoneDental Insurance InformationInsured's NameInsurance CompanyGroup No.Insured's EmployerInsured's Birth Date Date Format: MM slash DD slash YYYY Insured's ID/Policy NumberInsured's Phone №Do you have dual coverage?YesNoInsured's NameInsurance CompanyGroup No.Insured's Co. AddressInsured's EmployerInsured's Birth Date Date Format: MM slash DD slash YYYY I authorize the following1) 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 SignatureDental 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 Date Format: MM slash DD slash YYYY How often do you brush your teeth?How often do you floss?What type of toothbrush do you use?ManualBattery operatedMedical 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-workerI prefer to be contacted during the day by:Cell PhoneOffice PhoneHome PhoneEmail: Other:May we use patient's photo for educational and promotional purposes?YesNoEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
