New Patient Information Step 1 of 5 - Personal Information 20% CONFIDENTIAL PATIENT INFORMATIONDate* MM slash DD slash YYYY Patient's Name* SS # Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail* Birth Date* MM slash DD slash YYYY Sex* Marital Status* Occupation How did you hear about us?* Facebook Google Sign Phone Book Referring Dentist Insurance Website PERSON RESPONSIBLE FOR ACCOUNTName* Relationship* SS # Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell Phone DENTAL INSURANCE INFORMATIONDo you have dental insurance?* Yes No Primary Insurance Company* Primary Insurance Company Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employee* Relationship* SS #* Employer* Policy #* Birth Date* MM slash DD slash YYYY HEALTH INFORMATIONPatient's Name* Date* MM slash DD slash YYYY Personal Physicians Name First Last Have you been hospitalized within the past 2 Years?* Yes No For What? Are you currently being treated by a physician?* Yes No For What? Are you currently taking any medications or drugs?* Yes No What? Have you ever received counseling for excessive use of alcohol and/or prescription drugs?* Yes No Are you allergic to any drugs?* Yes No What? Are you allergic to any metals or latex?* Yes No What? Do you bleed excessively upon injury?* Yes No Do you currently or have you ever used tobacco in any of the following forms?* None Vaping Smoking Chewing Are you pregnant? Yes No Check any of the following conditions that you have had or now have.* NONE AIDS Heart Murmer Heart Problem* Hepatitis Psychiatric Care Sexually Transmitted Diseases Osteoporosis Stroke Tuberculosis Other Diseases What other diseases? PERSON TO BE CONTACTED IN CASE OF EMERGENCYName* Relationship* Home PhoneWork Phone
