Step 1 of 4 25% PATIENT INFORMATIONName* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone*Cell Phone*Work Phone*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Social Security #*Sex*MaleFemaleEmergency Contact Name* First Last Emergency Contact Phone #*Emergency Contact Relationship* INSURANCE INFORMATIONInsurance Company*Responsible Person*Relationship to Patient*Employer*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Social Security #*Sex*MaleFemaleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country MEDICAL HISTORYPhysician's Name*Physician's PhoneDate of Last VisitMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you had any serious illnesses or operations?NoYesExplain Illness / Operation*Are you currently under physician care?NoYesExplain Physician Care*Are you pregnant?NoYesNursing?NoYesTaking Birth Control Pills?NoYesCheck if you have had any of the following: AIDS/HIV Positive Anaphylaxis Anemia Arthritis Rheumatism Artificial joints Asthma A topic (allergy prone) Back problems Blood disease Cancer Chemical dependency Chemotherapy Circulatory problems Cortisone treatments Cough, persistent Cough up blood Diabetes Epilepsy Fainting Food allergies Glaucoma Headaches Heart murmur Heart problems Hemophilia / Abnormal bleeding Herpes Hepatitis High blood pressure Jaw pain Kidney disease or malfunction Liver disease Material allergies (latex, wool, metal, chemicals) Mitral valve prolapse Nervous problems Pacemaker / Heart surgery Psychiatric care Rapid weight loss or gain Radiation treatment Respiratory disease Rheumatic / Scarlet fever Shingles Shortness of breath Skin rash Spinal bifida Stroke Surgical implant Swelling of feet or ankles Thyroid disease or malfunction Tobacco habit Tonsilitis Tuberculosis Ulcer, Colitis Venereal disease List medications you are currently taking (if any)Allergies DENTAL HISTORYWhat would you like us to do?*Are you in discomfort today?*Former Dentist*Former Dentist Address*PhoneDate of last dental care*Date of last x-rays*Check if you have had problems with any of the following Bad breath Bleeding gums Clicking or popping jaw Food collection between teeth Grinding or clenching teeth Loose teeth or broken filings Periodontal treatment Sensitivity to cold Sensitivity to hot Sensitivity to sweets Sensitivity when biting Sores / growths in mouth How often do you brush?*How often do you floss?*How do you feel about the appearance of your teeth?*Have you ever experienced an adverse reaction during or in conjunction with a medical/dental procedure?*NoYesOther information about your dental health or previous treatmentHow did you hear about our dental practice? Pass by or live near by Heard about us from friend or family PennySaver Yellow Pages Beacon Free Press Insurance Company Southern Dutchess Healthy Living Reward Credit Internet or Website TV Commercial Other What other source did you hear about our dental practice?* This iframe contains the logic required to handle Ajax powered Gravity Forms.
