New Patient Form

New Patient Forms

PATIENT INFORMATION

Date

Social Security #

Patient

Address

City

State Zip

E-mail

Sex Age

Birthdate

Occupation

Patient Employer/School

Employer/School Address

Employer/School Phone

Spouse's Name

Spouse's Birthdate

Spouse's SS#

Spouse's Employer

Whom may we thank for referring You?

Preffered Location?

DENTAL INSURANCE

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Is patient covered by additional insurance?

Subscriber's Name

Subscriber's Birthdate

Subscriber's SS #

Relationship to Patient

Insurance Co.

Group #

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with   and assign directly to

Westwind Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financilally responsible for alll charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Westwind Dental may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benifits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.


Signature of Patient, Parent, Guardian or Personal Representative
Please print name of Patient, of Patient, Parent, Guardian or Personal Representative
Date

Relationship to Patient

PHONE NUMBERS

Home

Work Ext

Cell Phone

Spouses's Work

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT
(Specify someone who does not live in your household.)

Name

Relationship

Home Phone

Work Phone


DENTAL HISTORY

Reason for today's visit

Former Dentist

City/State

Date of last dental visit

Date of last dental X-rays

Place a mark on 'yes' or 'no' to indicate if you have had any the following:

Bad Breath

Bleeding Gums

Blisters on lips or mouth

Burning sensation on tongue

Chew on one side of mouth

Cigrette, pipe, or cigar smoking

Clicking or popping jaw

Dry mouth

Fingernail biting

Foood collection between the teeth

Foreign Objects

Grinding Teeth

Gums Swollen or Tender

Jaw Pain or Tiredness

Lip or cheek biting

Loose teeth or broken fillings

Mouth Breathing

Mouth Pain, Brushing

Orthodontic Treatment

Pain around Ear

Periodontal Treatment

Sensitive to Cold

Sensitive to Heat

Sensitive to Sweets

Sensitive when biting

Sores or growths in your mouth

How often do you Floss?

How often do you Brush?


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 lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).   

Place a mark on "yes" or "no" to indicate if you have had any of the folllowing :

AIDS/HIV

Arthritis, rheumatism

Artificial Heart Valves

Artificial Joints

Asthma

Bleeding Abnormallly, with Extractions or Surgery

Blood Disease

Cancer

Chemical Dependency

Chemotherapy

Circulatory Problems

Congenital Heart Lesions

Cortisone Treatments

Cough, persistent or bloody

Diabetes

Emphysema

Do you wear contact lenses?

Epilepsy

Fainting or Dizziness

Glaucoma

Headaches

Heart Murmur

Heart Problems

Hepatitis Type

Herpes

High Blood Pressure

Jaundice

Jaw Pain

Kidney Disease

Liver Disease

Low Blood Pressure

Mitral Valve Prolapse

Nervous Problems

Pacemaker

Psychiatric Care

Respiratory Disease

Rheumatic Fever

Scarlet Fever

Shortness of Breath

Sinus Trouble

Skin Rash

Special Diet

Stroke

Swollen Feet or Ankles

Swollen Neck Glands

Thyroid Problems

Tonsillitis

Tuberculosis

Tumor or Growth on Head or Neck

Ulcer

Venereal Disease

Weight Loss, Unexplained

Radiation Treatment

Women

Are you Pregnant?

Taking Birth Control Pills?

Due Date

Are you Nurshing?


MEDICATIONS


List any medications you are currently taking and the correlating diagnosis:

Pharmacy Name

Phone

ALLERGIES


Aspirin

Barbiturates (Sleeping Pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

UPDATES

(To be filled in at future Appointsments)

Has there been any changes in your health since your last dental appoinment?    

For what conditions?

Are you taking any new medications?

If so, what?

Patient's Signature

Date
Doctor's Signature
Date

Has there been any changes in your health since your last dental appoinment?    

For what conditions?

Are you taking any new medications?

If so, what?

Patient's Signature

Date
Doctor's Signature
Date