New Patient Form Patient InformationFirst Name* Last Name* Email* Birth Date MM slash DD slash YYYY S.S.N Gender-Choose-MaleFemaleAddress Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneWork PhoneFaxCell Carrier School (If student) Grade Marital Status--Choose--SingleMarriedSeperatedDivoredWidow(er)Employer/Occupation Name Of Dentist Date Of Last Visit MM slash DD slash YYYY Whom May We Thank For Recommending Us? Names & Ages Of Other Siblings/Children Related Patients That Are Or Have Been Under Our Care Responsible Party Information (Please Complete If Patient Is A Minor)Name Birth Date MM slash DD slash YYYY Marital Status--Choose--SingleMarriedSeperatedDivoredWidow(er)Home PhoneWork PhoneCell PhoneFaxSSN Email Employer Occupation No. Of Years Employed Mailing Address (If Different From Patient’s) Street Address City State / Province / Region ZIP / Postal Code How Many Years At This Address? Previous Address (If Less Than 3 Yrs) Insurance InformationPolicyholder’s Name Relationship To Patient Employer/Occupation S.S.N Birth Date MM slash DD slash YYYY Insurance Company Insurance Co. PhoneMember ID Group No. Insurance Co. Address Street Address City State / Province / Region ZIP / Postal Code * I understand that I am financially responsible for all charges for services to me/my dependent, including the balance remaining after payment of possible insurance benefits. I hereby authorize and direct payment of the dental benefits otherwise payable to me directly to Dr. Bui’s office. I consent to your use and disclosure of my/my dependent’s protected health information for insurance claims. *By providing my cell phone number, I am consenting to be contacted by Dr.Bui's office on matters related to treatment, financial account, insurance and practice promotions. Date* MM slash DD slash YYYY Medical/Dental HistoryMedical History Abnormal Bleeding ADD/ADHD Anemia Arthritis Artificial Bones/Valves Asthma Cancer Diabetes Difficulty Breathing Dizziness or Fainting Epilepsy or Seizures Hepatitis HIV/AIDS High/Low Blood Pressure Kidney Problems Liver Problems Pregnancy Now Psychiatric Problems Sleep Apnea Sinus Problems Stroke Substance Abuse Tobacco Use Thyroid Problems Tuberculosis Venereal Diseases Dental History Any Previous Orthodontic Consultations Clenching/Grinding Difficulty Swallowing/Chewing Mouth Breathing Speech Problems Tongue Thrust Thumb/Finger/Lip Sucking TMJ Problems Injuries to Face or Mouth Missing/Extra Teeth Patient’s Physician Last Physical Exam Is the patient allergic to latex, nickel, penicillin, etc.--Choose--YesNoList Allergies Is the patient taking/has the patient taken Bisphophosphonates?--Choose--YesNoDoes the patient need to be pre-medicated for dental treatment?--Choose--YesNoReason Has the patient ever been hospitalized?--Choose--YesNoReason Is the patient under the care of a physician at this time?--Choose--YesNoReason Emergency Contact Information (nearest relative not living with patient)Name Address Street Address City State / Province / Region ZIP / Postal Code Relationship Home PhoneCell PhoneWork Phone* I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and that it is my responsibility to inform this office of any changes in my/my child’s medical status. I authorize the dental staff to perform the necessary dental services that may be needed.
