New Patient Forms

    Patient Information

    First Name*
    Last Name*
    Sex*
    Address*
    Apt #
    Marital Status*
    City*
    State*
    Zip Code*
    Birth Date*
    Email*
    Employer*
    Occupation*
    Home Phone*
    Work Phone*
    Cell Phone*
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    Emergency Contact Information

    Emergency contact name*
    Phone Number*
    Physician Name*
    Phone Number*
    Are any other members of your family patients of this office?*
    Name
    Who may we thank for referring you to our office?

    Responsible Party Information if same as above, leave blank

    Name
    Sex
    Address
    City
    State
    Zip Code
    Birth Date
    Employer
    Occupation
    Relationship to patient
    Home Phone
    Work Phone
    Cell Phone

    Subscriber Information

    Name
    ID #
    Birth Date
    Employer
    Relationship to patient

    Dental Insurance Information

    Dental Insurance Name
    Group #
    Phone Number

    Consent for Services

    I hereby authorize Esthetix Dental Spa and staff to take and all necessary x-rays, study models, and photographs deemed necessary to make a thorough diagnosis of my dental needs. Upon such diagnosis, I authorize Esthetix Dental Spa and/or staff to perform any recommended treatment manually agreed upon. I agree to the use of anesthetics sedatives, and other medication as necessary. I fully understand that the use of medications and anesthetic agents embodies certain risks. I understand that I can request a full recital of any such risks of potential complications.

    Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

    Signature of guarantor of payment/responsible party*
    Date*
    Relationship to patient*

    Information that you feel insignificant could be directly related to your dental health. Answering the following questions will provide us with a thorough understanding of your physical condition for proper recommendations regarding your dental care. This information is strictly confidential. Thank you for completing all questions in detail.

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    Dental History

    What is the reason for this appointment?*
    Are there any specific dental problems we should know about?*
    Are you aware of any decay or cavities?*
    How often do you floss?*
    Do you suffer from consistent bad breath or bad taste?*
    How often do you brush?*
    Do you have any jaw cracking or pain?*
    Texture of your toothbrush?*
    Do you clench or grind your teeth?*
    When was your last cleaning?*
    Have you had periodontal treatment?*
    When were the last x-rays taken?*
    Have you had orthodontic treatment?*
    Name of your previous dentist?*
    How would you describe your dental health?*

    Medical History

    Any heart problems*
    Heart attack*
    Angina*
    Bypass*
    Pacemaker*
    Stroke*
    High Blood Pressure*
    Low Blood Pressure*
    Heart Murmur*
    Mitral Valve Prolapse*
    Heart Valve Defect*
    Heart Valve Replacement*
    Rheumatic Fever*
    Bleeding Disorder*
    Anemia*
    Hemophilia*
    Sickle Cell Trait*
    Blood Transfusion*
    Artificial Joint*
    Do you smoke?*
    Lung/Breathing Problems*
    Asthma*
    Bronchitis*
    Emphysema*
    Tuberculosis*
    Sinus Trouble*
    Diabetes*
    Difficulty Hearing*
    Liver Problems*
    Hepatitis/Jaundice*
    Kidney Problems*
    Stomach Problems/Ulcers*
    Alcoholism*
    Drug Abuse*
    Nervous/Mental Disorder*
    Epilepsy/Seizures*
    Thyroid Problems*
    Adrenal/Pituitary*
    Allergic Reaction (Hives/Swelling):
    Penicillin*
    Erythromycin*
    Sulfa*
    Codeine*
    Aspirin*
    Anesthetic*
    Latex*
    Other
    Infectious Diseases*
    HIV/AIDS*
    Cancer/Tumor*
    Growths*
    Chemotherapy*
    Radiation*
    Are You Pregnant?*
    How many months?
    Do you need to take antibiotic pre-medication prior to dental appointments?*
    Why?
    Do you have any current health problems not listed above?*
    What?
    Is a physician currently treating you?*
    Why?
    Are you presently taking medications, pills or tonics?*
    Please list
    Physician's Name
    Phone Number
    Medical History Reviewed
    Date
    I have read the conditions of treatment and payment and agree to their content.
    Signature of patient, parent or guardian*
    Date*
    Relationship to Patient*
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