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MM slash DD slash YYYY
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Is the mailing address the same?
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Mailing Address
Mailing Address
City
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American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Ohio
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Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Previous Address
Previous Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
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*
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Single
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Do you play a musical instrument?
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Type of Instrument?
Hobbies?
Who may we thank for referring you to our office?
*
Your email address?
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No. of years employed?
Insurance Information
Primary Insured's Name
DOB
MM slash DD slash YYYY
Primary Insured's SSN
Insurance Co.
Insurance Phone
Insurance Co. Address
Insurance Co. Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Insured's Employer
Group #
Do you have dual coverage?
Yes
No
Secondary Insured's Name
Secondary Insured's DOB
MM slash DD slash YYYY
Secondary Insured's SSN
Secondary Insurance Co.
Secondary Insurance Phone
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Secondary Insurance Co. Address
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Virgin Islands, U.S.
Wallis and Futuna
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Secondary Insured's Employer
Secondary Group #
Medical/Dental History
Physician's Name
Physician's Phone
Dentist's Name
Dentist's Phone
Are you currently under any medical treatment?
*
Yes
No
What medical treatment(s)?
Do you have pain, clicking, and/or poppinig noises in the jaw?
Yes
No
If so, explain
Are you aware of either clenching or grinding of teeth?
Yes
No
If so, explain
Do you have frequent headaches?
Yes
No
How often?
Do you have ear problems? (Aches, ringing, dizziness, fullness)
Yes
No
If so, explain
Do you have difficulty breathing through the nose?
Yes
No
If so, explain
Do you have habits such as nail biting, finger or thumb sucking, lip or cheek biting?
Yes
No
If so, explain
Do you have speech problems, or are you in speech therapy?
Yes
No
If so, explain
Have you had your tonsils and/or adenoids removed?
Yes
No
If so, explain
Has there been any history of:
Joint swelling
Asthma
TB
Aids
Kidney
Liver condition
Epilepsy
Rheumatic fever
Other
Other major illnesses?
Do you bleed easily?
Yes
No
If so, explain
Is there a tendency to faint or become dizzy?
Yes
No
If so, explain
Do you have allergies? (Sulphur, penicillin, novocain)
Yes
No
Explain the allergies:
Are you currently taking any medication?
Yes
No
List medication(s):
Do you have a heart condition?
Yes
No
Do you pre-medicate?
Yes
No
Cardiologist?
Do you have sleep apnea?
Yes
No
Do you smoke or chew tobacco?
Yes
No
If so, explain
Have there been any injuries to the teeth?
Yes
No
If so, explain
Have you had any permanent teeth extracted?
Yes
No
If so, explain
Have we treated any other family members?
Yes
No
If so, who?
I certify that the information provided on this form is correct to the best of my knowledge. I understand that it is my responsibility to report any changes.
*
I agree
The below portion of this form will be printed and signed in office. There is no need to fill out online.
Patient Name:
Patient Signature:
Date Signed:
Staff Signature:
Date Signed:
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