Adult Patient Form

Step 1 of 5

20%

1. About You
Name*
First Last
I prefer to be called:
Gender*
- Male
- Female
Birthdate
Date Format: MM slash DD slash YYYY
Age*
Social Security #:*
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Marital Status
- Single
- Married
- Divorce
- Widowed
- Separated
Email*
Home Phone*
Work Phone
Employer
How long there?
Occupation
Where & when are the best times to reach you?
General Dentist
Last Visit Date
Date Format: MM slash DD slash YYYY

2. Spouse Information
His/Her Name
First Last
Employer
Person Responsible for Account*
Work Phone
Home Phone*
Billing Address*
Street Address Address Line 2 City State ZIP Code
Relation
Social Security #*
Employer
Driver's License #*

3. Dental/Orthodontic Insurance
Do you have orthodontic coverage?*
- Yes
- No
Insurance Co. Name
Insurance Co. Address
Insurance Co. Phone
Subscriber ID#
Relation
Insure'd Birthdate
Date Format: MM slash DD slash YYYY
Social Security #
Insured's Employer

4. Medical History
Do you have a personal physician?*
- Yes
- No
Physician's Name
Physician's Phone
Date of Last Visit
Date Format: MM slash DD slash YYYY
Your current physical health is:*
- Good
- Fair
- Poor
Are you currently under the care of a physician?*
- Yes
- No
Are you currently using any tobacco products?*
- Yes
- No
Are you taking any prescription / over-the-counter drugs?*
- Yes
- No
Please list each one:*
For Women
Are you taking birth control pills?
- Yes
- No
Are you pregnant?
- Yes
- No
Are you nursing?
- Yes
- No
Have you ever had any of the following diseases or medical problems?
Anemia/Radiation Treatment*
- Yes
- No
Artificial Bones/Joints*
- Yes
- No
Artificial Valves*
- Yes
- No
Asthma/Arthritis*
- Yes
- No
Blood Transfusion*
- Yes
- No
Bruxism/Grinding*
- Yes
- No
Cancer/Chemotherapy*
- Yes
- No
Clenching*
- Yes
- No
Congenital Heart Defect*
- Yes
- No
Diabetes/Tuberculosis(TB)*
- Yes
- No
Difficulty Breathing*
- Yes
- No
Drug/Alchol Abuse*
- Yes
- No
Emphysema/Glaucoma*
- Yes
- No
Epilepsy/Seizures/Fainting Spells*
- Yes
- No
Fever Blisters/Herpes*
- Yes
- No
Head and Neck Pain*
- Yes
- No
Headaches*
- Yes
- No
Heart Attack/Stroke*
- Yes
- No
Heart Murmur*
- Yes
- No
ADD/ADHD/Aspergers*
- Yes
- No
Heart Surgery/Pacemeaker*
- Yes
- No
Hemophilia/Abnormal Bleeding*
- Yes
- No
Hepatitis*
- Yes
- No
High/Low Blood Pressure*
- Yes
- No
HIV+/AIDS*
- Yes
- No
Hospitalized for Any Reason*
- Yes
- No
Keloid Formations*
- Yes
- No
Kidney Problems*
- Yes
- No
Mitral Valve Prolapse*
- Yes
- No
Psychiatric Problems*
- Yes
- No
Rheumatic/Scarlet Fever*
- Yes
- No
Severe/Frequent Headaches*
- Yes
- No
Shingles*
- Yes
- No
Sinus Problems*
- Yes
- No
Sleep Apnea*
- Yes
- No
Snoring*
- Yes
- No
TMJ Pain*
- Yes
- No
Ulcers/Colitis*
- Yes
- No
Veneral Disease*
- Yes
- No
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following:
Aspirin*
- Yes
- No
Any Metal/Plastic*
- Yes
- No
Codeine*
- Yes
- No
Dental Anesthetics*
- Yes
- No
Erythromycin*
- Yes
- No
Latex*
- Yes
- No
Penicillin*
- Yes
- No
Tetracycline*
- Yes
- No
Other*
- Yes
- No
Please list any other drugs that you are allergic to:

5. Patient Signature
I understand that the information that I have given today is correct to the best of my knowledge. I also understand confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services that I may need during diagnosis and treatment with my informed consent.
Signature of Parent or Guardian (Sign with Mouse)*
Date*
Date Format: MM slash DD slash YYYY

Schedule Your FREE Consultation Now

Full Name*
Phone*
Email*

Contact

128 Colombia Turnpike 
Florham Park, NJ 07932

973.408.9183

Hours

Monday: 11am - 6:30pm

Tuesday - Thursday: 12pm - 8pm

Free Consult

Adult Patient Form

Step 1 of 5

1. About You

2. Spouse Information

3. Dental/Orthodontic Insurance

4. Medical History

For Women

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following:

5. Patient Signature