Signature Smilez

Patient Information

Full Name

Date

Address

City

Postal Code

Home #

Cell #

Email Birthdate

Gender

Male Female

Marital Status

Single Married Divorced Widowed Separated Child (Under 21)

Emergency Contact

Relationship

Emergency Phone # Whom may we thank for referring you? How did you hear about us?

Internet Outside Sign Mail/Flyer Location Other

Dental Insurance

Do you have dental insurance?

Yes No

Who is financially responsible?

Self Other

If Other, provide name & contact:

Primary Insurance

Insurance Company

Policy #

Certificate / ID #

Subscriber Name

Subscriber DOB

Secondary Insurance (Optional)

Insurance Company

Policy #

Certificate / ID #

Subscriber Name

Subscriber DOB

Medical History

Are you under the care of a physician? Any serious illness or surgery? Hospitalized before? Medications currently taking Do you bruise easily or bleed longer?

Yes No

Do you smoke? How many per day? Women: Are you pregnant? Allergy to: Local anesthetic? Antibiotics, sedatives or painkillers? Any medical conditions?

Dental History

Reason for today’s visit

How often do you see a dentist?

Last dental visit

Teeth sensitivity? Bad breath or bad taste? Do your gums bleed? Jaw cracking, popping or grinding? Any previous dental treatment problems? Past procedures: Rate your smile (1 - 10) What would you like changed?

Consent & Release

I consent to necessary dental procedures. I consent to the storage of my personal information and photos. I authorize sharing of my records with insurance/health providers. I consent to receiving reminders via SMS, email, or phone.

Signature