1. finance
2. personal finance
3. insurance

Welcome! We are pleased to welcome you to our practice.
Please take a few minutes to fill out this form as completely as you
can. If you have questions we’ll be glad to help you. We look forward
to working with you in maintaining your dental health.
Patient Information
Name ___________________________________________________ Social Security # ___________________________
Last Name
First Name
Initial
Address ___________________________________________________________________________________________
City _ __________________________ State ______ Zip ________________ Home Phone _______________________
Cell Phone _ _______________________ Email __________________________________________________________
Sex qM qF Age _____ Birth Date ____ /____ /___ qSingle qMarried qWidowed qSeperated qDivorced
Patient Employed by _ ________________________________________ Occupation ___________________________
Business Address ____________________________________________ Business Phone _______________________
Business Email _____________________________________________________________________________________
Whom may we thank for referring you? _______________________________________________________________
Notify in case of emergency _ ____________________________________ Home Phone _______________________
Cell Phone _ ________________________________ Business Phone _ _______________________________________
Email _____________________________________________________________________________________________
Primary Insurance
Person Responsible for Account ______________________________________________________________________
Last Name
First Name
Initial
Relation to Patient ___________________ Birth Date _____ /_ ____ /_____ Social Security # ____________________
Address ___________________________________________________________________________________________
City _ __________________________ State ______ Zip _ _______________ Home Phone _______________________
Cell Phone _ _______________________ Email __________________________________________________________
Person Responsible Employed by _ _____________________________ Occupation ___________________________
Business Address _____________________________________________ Business Phone _______________________
Business Email _____________________________________________________________________________________
Insurance Company ___________________________________________________ Phone _______________________
Insurance Email ____________________________________________________________________________________
Contract # ________________________ Group # ____________________ Subscriber # _ _______________________
Name of other dependants under this plan _ ___________________________________________________________
Additional Insurance
Is patient covered by additional insurance? qYes qNo
Subscriber Name ____________________ Relation to Patient ___________________ Birth Date _ ____ /_____ /_____
Address (if different from patient) ____________________________________________________________________
City _ __________________________ State ______ Zip _________________ Home Phone Cell Phone _ _______________________ Email __________________________________________________________
Subscriber Employed by _ ______________________________________ Business Phone _______________________
Business Email _____________________________________________________________________________________
Insurance Company ___________________________________________________ Phone _______________________
Insurance Email ____________________________________________________________________________________
Contract # _________________________ Group # ____________________ Subscriber # ________________________
Name of other dependants under this plan _ ___________________________________________________________
Dental History
What would you like us to do today? ___________ Are you in dental discomfort? ________
Former Dentist ______________________________ Address _______________________________________________
Dentist’s Email _______________________________________________________ Phone _______________________
Date of last dental care _________________________ Date of last x-rays ____________________________________
Check ( 3 ) Yes or No if you have had problems with any of the following:
qY qN Bad breath
qY qN Food collection between teeth qY qN Gum disease
qY qN Bleeding gums qY qN Grinding or clenching teeth qY qN Sensitivity to cold
qY qN Clicking or
qY qN Loose teeth or broken fillings qY qN Sensitivity to hot
popping jaw
qY qN Sensitivity to sweets
qY qN Sensitivity when biting
qY qN Sores or growths in mouth
How often do you brush? _ ________________________________ Floss? _ __________________________________
Is there anything about the appearance of your teeth that you would like to change? ________________________
Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? qY qN
Other information about your dental health or previous treatment ________________________________________
Medical History
Physician’s name ___________________________________ Phone _______________________
Date of last visit __________________________________ Have you had any serious illness or operations? qY qN
If yes, describe _____________________________________________________________________________________
Are you currently under physician care? qY qN If yes, describe _ ________________________________________
Have you ever had a blood transfusion? qY qN If yes, give approximate dates _ ___________________________
Have you ever taken Fen-Phen/Redux? qY qN
Have you ever used a bisphosphonate? Brand names include Fosamax, Actonel, Atelvia, Didronel & Boniva. qY qN
Women: Are you pregnant? qY qN
Nursing? qY qN
Taking birth control pills? qY qN
Check ( 3 ) Yes or No if you have had problems with any of the following:
qY qN AIDS/HIV Positive
qY qN Anaphylaxis
qY qN Anemia
qY qN Arthritis, Rheumatism
qY qN Artificial heart valves
qY qN Artificial joints
qY qN Asthma
qY qN Atopic (allergy prone)
qY qN Back problems
qY qN Blood disease
qY qN Cancer
qY qN Chemical dependency
qY qN Chemotherapy
qY qN Circulatory problems
qY qN Cortisone treatments
qY qN High blood pressure
qY qN Cough, persistent
qY qN Jaw pain
qY qN Cough up blood
qY qN Kidney disease
or Malfunction
qY qN Diabetes
qY qN Epilepsy
qY qN Liver Disease
qY qN Fainting
qY qN Material allergies
(latex, wool, metal,
qY qN Food allergies
chemicals)
qY qN Glaucoma
qY qN Headaches
qY qN Mitral valve prolapse
qY qN Heart Murmur
qY qN Nervous problem
qY qN Heart problems
qY qN Pacemaker/
Heart Surgery
Describe ____________________
qY qN Hemophilia/
qY qN Psychiatric care
Abnormal bleeding
qY qN Rapid weight gain/loss
qY qN Herpes
qY qN Radiation treatment
qY qN Hepatitis
qY qN Respiratory disease
qY qN Rheumatic/Scarlet fever
qY qN Shingles
qY qN Shortness of breath
qY qN Skin rash
qY qN Spina Bifida
qY qN Stroke
qY qN Surgical implant
qY qN Swelling of feet
or ankles
qY qN Thyroid disease
or malfunction
qY qN Tobacco habit
qY qN Tonsillitis
qY qN Tuberculosis
qY qN Ulcer/Colitis
qY qN Venereal disease
Is patient currently taking any medications? If yes, list all: _______________________________________________
Does patient have drug allergies? If yes, list all: _ _______________________________________________________
I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been answered accurately.
I understand that providing incorrect information can be dangerous to my health. I authorize and request my insurance company to pay directly
to Dr. M. Sanjeevan all applicable insurance benefits. I understand that my dental insurance is a contract between the insurance carrier and me,
and not between Dr. M. Sanjeevan and me. I am ultimately financially responsible for all dental fees the above named patient or I incur during
the course of treatment with Dr. M. Sanjeevan*. I further hereby acknowledge and agree that at least 24 hours notice is required to cancel an
appointment without incurring broken appointment charges. I also grant permission to be called concerning my account and appointments. I
authorize the release of my, and/or the above named patients records to a third party.
7 Signature _ _________________________________________________________________
(or Guardian if patient is a minor)
*For your convenience we accept cash, Visa, MasterCard and Discover
Date ___/___/___