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Patient Information

First Name

Last Name

MI

Date

MM slash DD slash YYYY

Preferred Name

Gender

Male

Female

Address

Home Address City State ZIP

Cell Phone

Home Phone

Email

Employer

Occupation

Name(s) of Spouse and/or Children

Referred By

Full Time Resident?

Yes

No

Primary Insurance

Insurance Company

Employer

Policy Holder

Birthdate

MM slash DD slash YYYY

SSN

Group ID

Subscriber/Member ID

Address

if different than patient

Phone

Emergency Contact

Name

Relation

Phone

Pharmacy Information

Name

Phone

Address

if different than patient

DENTAL HEALTH HISTORY

Last Dental Visit

MM slash DD slash YYYY

Last Dental Cleaning

MM slash DD slash YYYY

Last Dental X-rays

MM slash DD slash YYYY

Previous Dentist

Locatiom

Reason for your visit

How often do you brush your teeth?

Floss?

Do you have missing teeth?

Yes

No

Are you interested in replacing them?

Yes

No

Have you ever had orthodontic braces?

Yes

No

Date

MM slash DD slash YYYY

Have you ever been treated for periodontal disease?

Yes

No

Date

MM slash DD slash YYYY

Consent and other required Information(Required)

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Regular Dental Checkups
Root Canal Treatment
Sealants
Teeth Extractions

Menu

General Dentistry
Cosmetic Dentistry
Teeth Whitening Treatment
Veneers
Crowns and Bridges
Dentures
Inlays & Onlays
Invisalign
Mouth Guards
Pediatric Dental Services
Periodontal Services
Regular Dental Checkups
Root Canal Treatment
Sealants
Teeth Extractions

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9131 College Parkway #150 Fort Myers, FL 33919

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