Please fill out our new patient form:

PATIENT INFORMATION

Date:
ID#/SS#:
Patient:
Address:
City: State: Zip:
Sex:
Age:
Birthdate:
Marital status:

Occupation:
Employer:
Employer Address:
City: State: Zip:
Employer Phone:
Spouse's Name:
Whom may we thank for referring you?

DENTAL INSURANCE

Who is responsible for this account?
Relationship to Patient:
Insurance Co.:
Group #:
Is patient covered by additional insurance?
Subscriber's Name:
Birthdate: SS#:
Relationship to Patient:
Insurance Co.:
Group #:

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with and assign directly to Westwind Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by Insurance, I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Agree: Not Agree:

Relationship: Date:

CONTACT INFORMATION

Home: Work: Ext: Cell Phone:

Email: Spouse's Work Phone: Best Time and place to reach you:

Spouse's Work Phone:

DENTAL HISTORY

Reason for today's visit:

Former Dentist:
City/State:
Date of last dental visit:
Date of last dental X-ray:
Select YES if you have had any of the following:

Bad breath
Bleeding gums
Blisters on lips or mouth

Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting

Loose teeth or broken fillings
Mouth Breathing
Mouth pain, brushing
Orthodontic treatment
Periodontal treatment
Pain around ear
Sensitivity to cold
Sensitivity to hot
Sensitivity to sweet
Sensitivity when biting
Sores or growths in your mouth
How often do you floss?
How often do you brush?

HEALTH HISTORY

Have you ever taken any of the group of drugs collectively referred ,to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) anu Redux (dexfenfluramine)

Select "YES" if you have had any of the following:

AIDS/HIV
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Bleeding abnormally with extractions or surgery
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, persistent or bloody
Diabetes

Emphysema
Epilepsy
Fainting or dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hepatitis Type
Herpes
High Blood Pressure
Jaundice
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Psychiatric Care

Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Stroke
Swelling of Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor or growth on head or neck
Ulcer
Venereal Disease
Weight Loss, unexplained

Do you wear contact lenses?

Women: Are you pregnant?
Due date: Are you nursing? Taking birth control pills?

MEDICATIONS	ALLERGIES
List any medications you are currently taking and the correlating diagnosis: Pharmacy Name: Phone:	Aspirin Barbiturates (sleeping pills) Codeine Iodine Latex	Local Anesthetic Penicillin Sulfa Other:

UPDATES (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment?
For what conditions?
Are you taking any new medications?     If so, what?

Patient's Signature:       Date:
Doctor's Signature:        Date: