New Visit | Hallsville Family Dentistry

NEW PATIENT FORM

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First Name *

Last Name *

Birthdate (MM/DD/YYYY) *

Phone Number *

Address *

City *

State *

Zip Code *

Gender *

Marital Status *

Email Address *

Employer/School *

Employer/School Phone #

Employer/School Address

Employer/School City *

Employer/School State *

Employer/School Zip

Whom may we thank for referring you?

Emergency Contact *

Emergency Contact Phone # *

Are you the person financially responsible for this account? *

Financially Responsible Party

Full Name *

Relation to patient *

Address *

Phone Number *

Birthdate (MM/DD/YYYY) *

Bank *

Employer

Employer Phone #

Are you currently a patient at our office?

Email Address *

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Do you have dental insurance? *

Insurance Information

Name of insured *

Relation to patient *

Birthdate (MM/DD/YYYY) *

Date Employed (MM/YYYY) *

Employer *

Work Phone # *

Employer Address *

Employer City *

Employer State *

Employer Zip Code *

Insurance Company *

Insurance Address *

Insurance City *

Insurance State *

Insurance Zip *

How much is your deductible? *

How much have you used? *

Maximum Annual Benefit *

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Dental History

Reason for upcoming visit

Date of last dental care (MM/YYYY)

Date of last dental X-Rays

Former Dentist

Former Dentist Address

Have you had problems with any of the following? (please check all that apply)

How often do you floss? *

How often do you brush? *

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Medical History

Physician's Name *

Date of Last Visit (MM/YYYY)

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) and Reduc (dexfenfluramine) *

Have you had any serious illnesses or operations? *

If yes, please describe

Have you ever had a blood transfusion? *

If yes, give approximate dates

Have you had problems with any of the following? (please check all that apply)

List of medications you are currently taking and the correlating diagnosis:

Please List Any Allergies

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AUTHORIZATION & RELEASE

By clicking submit you agree that to the best of your knowledge, the above information is complete and correct. You understand that it is your responsibility to inform your doctor if you, or your minor child, ever have a change in health. You certify that you and/or your dependent(s) have insurance with the company listed (if listed) and assign directly to Hallsville Family Dentistry all insurance benefits, if any, otherwise payable to you for services rendered. You authorize the use of your signature on all insurance submissions. The above-named dentistry may use your health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determinig benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from today's date. Payment is due in full at the time of treatment unless prior arrangements have been approved.

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