Adult Patient Information Form

Adult Patient Information

474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080
856-582-1000

Patient Information

Name (last, first, middle):

SS#:

Drive Lic #:

Home #:

Cell #:

Email:

Home Address:

City:

State:

Zip:

Gender: M F

Age:

Date of Birth:

Single Married Widowed Separated Divorced

Patient Employed By:

Occupation:

Business Address:

Business Phone:

Full-Time Student: Yes No

Name of College:

City & State:

How did you hear about us?: Yellow Pages Family

Other

In case of emergency who would be notified?

Phone:

Primay Insurance

Person Responsible for Account (last, first, middle):

Relationship to patient:

Insured's Birthdate:

Insured's SS#:

Address (If different than patient):

Phone #:

City:

State:

Zip:

Person Responsible Employed By:

Occupation:

Business Address:

Business Phone:

Insurance Company:

Contract #:

Group #:

Subscriber #:

Name of other dependents covered under this plan:

Additional Insurance

Patient Covered by Additional Insurance:

Person Responsible for Account (last, first, middle):

Relationship to patient:

Insured's Birthdate:

Insured's SS#:

Address (If different than patient):

Phone #:

City:

State:

Zip:

Person Responsible Employed By:

Occupation:

Business Address:

Business Phone:

Insurance Company:

Contract #:

Group #:

Subscriber #:

Name of other dependents covered under this plan:

The above information is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form are solely my responsibility. We reserve the right to charge for appointments cancelled or failed without 24 hours advance notice. Weekdays after 4PM and Saturdays will automatically be charged. Payment is due in full at time of treatment unless prior arrangements have been approved. Balances unpaid after 90 days are subject to a late charge of 1.5% per month, and may be reported to the credit bureaus at our discretion. I understand that by signing below I accept financial responsibility for all charges whether or not paid by insurance.

Signature of person responsible:

Date:

Dental History

Reason for Today's Visit:

Previous Dentist(s):

Address:

Date of last dental care:

Date of last dental x-rays:

Select any of the following that apply:

Bad Breath

Loose teeth or broken fillings

Sensitivity when biting

Grinding teeth

Sensitivity to sweets

Food collection between teeth

Sensitivity to hot

Clicking or Popping Jaw

Sensivity to cold

Bleeding Gums

Periodontal treatment

Sores or growths in your mouth

Do you like your smile? Yes No

Would you like to have whiter teeth? Yes No

How often do you brush?

How often do you floss?

Have you ever experienced an adverse reaction during or in conjuction with a medical or dental procedure? Yes No

Other information about your dental health or previous treatment:

Medical History

Physician's Name:

Date of Last Visit:

Have you had any serious illnesses or operations? Yes No

If yes, please describe:

Have you ever had a blood transfusion? Yes No

If yes, give approximate dates:

(Woman) Are you pregnant?? Yes No

Nursing? Yes No

Taking birth control pills? Yes No

Select any of the following that apply:

Other:

Medications

List any medications being taken: (including aspirin, contraceptive, coumadin)

Pharmacy Name:

Phone:

Allergies

Aspirin

Barbiturates (Sleeping Pills)

Codeine

Penicillin

Sulfa

Anesthetic

Other:

Signature of person responsible:

Date: