New Patient Form

Welcome to Malverne Dental Care! Please fill out the form below so we may provide you with the best possible care. Thanks.

Today's Date *

Are you filling out this form for *

You
Your child

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Best Phone Number *

Email Address *

Date of Birth//

Age

Gender

Marital Status

Married
Single
Divorced
Widowed

Social Security Number

Child's Name *

First

Middle

Last

Child's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Best Phone Number *

Child's Date of Birth *//

Child's Age *

Gender of Child *

Child's Social Security Number

Child's School

Grade at school

Dental Insurance Information

Do you have Dental Insurance *

Primary Dental Insurance

Name of Company

Employer Name

Group Number

Insured's Name

Insured's ID Number

Insured's Social Security Number

Insured's Date of Birth//

Relationship to Patient

Parent
Self
Gaurdian
Other

Do you have Secondary Dental Insurance?

Secondary Dental Insurance

Name of Secondary Insurance Company

Group Number of Secondary Insurance Company

Employer Name

Insured's Name

Insured's ID Number

Insured's Social Security Number

Insured's Date of Birth (Secondary Insurance)//

Relationship to Patient

Parent
Gaurdian
Other

Getting to Know you

Is another member of your family a patient?

Their name

Relationship

Who referred you to us?

Incase of emergency who should we contact?

What's their phone number?

Financial Responsibility

Name of responsible party *

First

Last

Relationship to Patient

Social Security Number

Address

Address Line 1

City

State

Zip Code

Phone Number

Your Occupation

Employers Name

Employer's Address

Address Line 1

City

State

Employer's Phone

Your Spouse's Occupation

Name of Spouse's Employer

Address of Spouse's Employer

Address Line 1

City

State

Phone number of Spouse's Employer

Consent for Treatment

1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my dental needs.

2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anesthetics, sedatives and other medication as necessary, I fully understand that using anesthetic agents embodies certain risks, I understand that I can ask for a complete recital of any possible complications.

4. I give consent to the doctor's or designated staff's use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

5. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1 /2% late charge (I 8% APR) may be added to my account. If required, I also understand a check of my credit history may be made.

I understand and consent to the above *

Dental History

What is the reason for your visit today?

Date of last dental visit

Date of last dental cleaning

Date of last full mouth x-rays

What was done at your last dental visit

Previous Dentist's Name

Previous Dentist's Phone Number

How often do you have dental examinations?

Every 3 months
Every 6 months
Every 12 months
Less than every 12 months

Do you have any dental issues now?

Please tell us about it.

How often do you brush your teeth?

Three times per day
Two times per day
Once per day
Other 🙂

How often do you floss?

Once a day
Once every few days
Once per week
Other 🙂

What other dental aids do you use?

Waterpick, Toothpick, etc.

Are any of your teeth sensitive to

Hot or cold?
Sweets
Biting or chewing
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters or any other oral lesions?

Have you ever experienced:

Clicking or popping of the jaw?
Pain? (joint, ear, side of face)
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Sore muscles (neck, shoulders)?

Have you ever had

Orthodontic treatment?
Oral Surgery?
Periodontal treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?

Do you

Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth?
Mouth breath while awake or asleep?
Have tired jaws, especially in the morning?
Smoke or chew tobacco?

Are you satisfied with your teeth's appearance?

Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment?

What's your biggest concern?

Is there anything else you would like us to know?

Medical History

Have you been under the care of a medical doctor in the past two years?

For what?

Physician's Name

Physician's Phone

What medications do you currently take?

Are you aware of having an allergic (or adverse reaction) to any medication or substance?

Please explain

Have you been a patient in the hospital in the past 5 years?

Indicate which of the following you have had, or have at present. Check "yes" or "no" to each item.

Heart (Surgery, Disease, Attack)

Ulcers

Hepatitis A (infectious) B (serum)

Chest Pain

Venereal Disease

Congenital Heart Disease

Thyroid Problems

A.I.D.S.

Heart Murmur

Glaucoma

H.I.V. Positive

High Blood Pressure

Contact Lenses

Cold Sores/Fever Blisters

Mitral Valve Prolapse

Emphysema

Blood Transfusion

Artificial Heart Valve

Chronic Cough

Hemophilia

Heart Pacemaker

Tuberculosis

Sickle Cell Disease

Rheumatic Fever

Asthma

Bruise Easily

Arthritis/Rheumatism

Hay Fever

Liver Disease

Cortisone Medicine

Latex Sensitivity

Yellow Jaundice

Swollen Ankles

Allergies or Hives

Neurological Disorders

Stroke

Sinus Trouble

Epilepsy or Seizures

Diet (Special/ Restricted)

Radiation Therapy

Fainting or Dizzy Spells

Artificial Joints (hip, knee, etc.)

Chemotherapy

Nervous/Anxious

Kidney Trouble

Tumors

Psychiatric/Psychological Care

Diabetes

Do you smoke?

Have you gained more than 10 pounds in the past year?

Do you have or have you had any disease, condition or problem not listed?

Please tell us what it is.

Are you pregnant?

How many months?

Are you nursing?

Are you taking birth control pills?

By checking this box I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication. *

Yes I do