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2022-10-20T19:56:06-05:00
Patient Information Form
First Name
Last Name
Birthdate
MM slash DD slash YYYY
Primary Phone Number
Home Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Kentucky
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Maryland
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Northern Mariana Islands
Ohio
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Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Email
Sex
Male
Female
Relationship Status
Single
Married
Widowed
Divorced
Patient Employed By
Occupation
Preferred Pharmacy
In Case of Emergency, Please Notify
First
Last
Relationship
Emergency Contact Phone #
Dental Benefit Information
Dental Insurance Company
Dental Insurance Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Policy Holder
Policy Holder Birthdate
MM slash DD slash YYYY
Employer
Relationship to Patient
Self
Spouse
Parent or Guardian
ID Number
Group Number
Medical and Dental Information
Name of Referring Dentist
Have you been advised to take an antibiotic one hour prior to dental visits?
Yes
No
Date of last appointment with your Dental Hygienist
MM slash DD slash YYYY
How often do you brush?
Once a day
Twice a day
Three or more times a day
How often do you floss?
Once a day
Twice a day
Three or more times a day
Name of Medical Physician
Name of Clinic
List of current medications, including both prescription and over the counter, you are taking:
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