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New Patient Form

Preferred Office Location (required) Which office would you like to be seen at?

Wellington

Wichita

Anthony

No Preference

Is the Responsible Party also the Patient? (required)

Yes

No

The responsible party must be 18 or older.

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Responsible Party

Full Name (required)

Address (required)

Address 2

City (required)

State (required)

Zip Code (required)

Email address (required)

Phone (required)

Cell Phone

Work Phone

Date of Birth (required)

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1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Social Security #

Driver's Lic #

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Patient Information

Patient's Full Name (required)

Is the patient's address and phone number same as responsible party? (required)

Yes

No

Social Security #

Address (required)

City (required)

State (required)

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code (required)

Email address

Phone (required)

Work Phone

Cell Phone

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Patient Information

Sex

Male

Female

Marital Status

Single

Married

Divorced

Widowed

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Preferred Dentist?

Preferred Hygienist?

Preferred Pharmacy?

Other Preferences?

How did you learn about our office? (required)

Internet Search

Phone Book

Driving by

Friend

TV

Radio

Newsletter or other flyer

Other

Which friend may we thank?

An "other" source? Interesting, tell us more!

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Do you have medical insurance?

Yes, one medical insurance

Yes, more than one medical insurance

No

Many of our services may be paid through medical insurance. This question is regarding only medical insurance, not dental benefits.

Do you have dental benefits?

Yes

No

Do you have more than one dental insurance?

No

Yes, I have 2

Yes, I have more than 2

Insurance Information

Responsible Party is also a policy holder for the patient

Primary Medical Insurance Holder

Secondary Medical Insurance Holder

Primary Dental Insurance Policy Holder

Secondary Dental Insurance Holder

Please check ALL that apply!

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Primary Medical Insurance

Many of our services may be paid through your medical insurance. These questions refer to MEDICAL insurance, not dental.

Name of Primary Policy Holder:

Patient's Relationship to Policy Holder

Self

Spouse

Child

Other

Insured's Birthdate

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Employer

Insurance Company Name

Insured's Policy #

If you don't have the policy #, please enter the insured's social security #

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Secondary/Supplemental Medical Insurance

These questions are regarding your secondary or supplemental MEDICAL insurance, not dental. That is coming up next, if applicable!

Name of Policy Holder:

Patient's Relationship to Insured:

Self

Spouse

Child

Other

Insured's Social Security #:

Insured's Birthdate:

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Employer

Insurance Company Name:

Policy #

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Primary Dental Benefits

Name of Insured:

Patient's Relationship to Insured?

Self

Spouse

Child

Other

Insured's Social Security #:

Insured's Birthdate

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 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1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Employer

Insurance Company Name

Policy Holder #

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Secondary Dental Benefits

Name of Insured

Patient's Relationship to Insured

Self

Spouse

Child

Other

Insured's Birthdate

Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 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Insured's Social Security #

Employer

Secondary Insurance Company Name

Policy Holder's #

Don't forget to bring your cards for your medical and dental benefits to your appointment.

 

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Medical History

How would you describe your overall health?

Choose One: Excellent Good Average Fair Poor

Are you under the care of a physician?

Yes

No

Physician's Name

Is there a history of cancer in your family?

Yes

No

What type of cancer?

Have you ever had a serious head or neck injury?

Yes

No

Please Explain

Please List any medications you are taking:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes

No

Do you use tobacco?

Yes

No

Do you use controlled substances?

Yes

No

Are you pregnant or trying to get pregnant?

Yes

No

Are you allergic to any of the following?

Codeine

Penicillin/Amoxicillin

Aspirin

Metal

Clindamycin

Latex

Acrylic

Other

What else are you allergic to?

Do you have or are you experiencing any of the following?

Alzheimer's/Dementia

Anaphylaxis

Arthritis/Gout

Artificial Joint

Asthma

Artificial Heart Valve

Asthma

Bruise or Bleed Easily

Cancer

Chemotherapy/Radiation

Cold Sores/Fever Blisters

Congenital Heart Disease

Convulsions/Seizures

Diabetes

Drug Addiction

Emphysema

Fainting/Dizziness

Frequent Diarrhea

Headaches- Frequent

Heart Attack/Failure

Heart Disease/Trouble

Pacemaker

Hemophilia

Hepatitis A

Hepatitis B or C

HIV/AIDS

Herpes

High Blood Pressure

High Cholesterol

Hypoglycemia

Kidney Problems

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain in Jaw Joints

Parathyroid Disease

Psychiatric Care

Shingles

Sickle Cell Anemia

Sinus Trouble

Stomach/Intestinal Disease

Stroke

Swelling of Limbs

TMD

Ulcers

Do you have any illnesses not mentioned above?

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Dental History

Is your main concern TMD, headache, neck or facial pain related?

Yes

No

What are your present dental concerns?

How many professionals have you seen for this issue?

Choose One:

None

1

2-4

5-7

More than 7

Include dentists, physicians, chiropractors, therapists, etc.

Please list all professionals you have seen for this issue:

When was your last dental visit?

Choose One: Less than 3 months ago 3-6 months ago 6-12 months ago 1-2 years ago Over 2 years ago

When were your last dental x-rays?

Choose One: Less than 1 year ago Over one year ago

When was your last cleaning?

Choose One: Less than 6 months ago 6-12 months ago 1-2 years ago Over 2 years ago

Have you avoided regular dental care?

Yes

No

Why?

Are you happy with the appearance of your teeth?

Yes

No

Would you like your teeth to be whiter?

Yes

No

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Name of Previous Dentist

Would you like us to request your records from your previous dentist?

Yes

No

City and State of previous dentist

How would you rate your previous dental experience?

Choose One: Excellent Good Average Fair Poor

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Nearest Relative

Name of nearest relative not living with you?

Phone

Address

City

State

Kansas Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

 

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