New Patient Information Step 1 of 6 16% CONFIDENTIAL PATIENT INFORMATIONDate(Required) MM slash DD slash YYYY Patient Name(Required)SS #Address(Required) Street Address Address Line 2 City State 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 ZIP Code Your Email Address(Required) Enter Email Confirm Email Preferred Phone Number(Required)Preferred Method of ContactEmailPhoneBirth Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex(Required)Marital Status(Required)OccupationHow did you hear about us?(Required) Facebook Google Website Mail Referring Dentist Other PERSON RESPONSIBLE FOR THE ACCOUNTAre you responsible for the account?(Required) Yes No Name(Required) First Last Relationship(Required)SS #Address(Required) Street Address Address Line 2 City State 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 ZIP Code Your Email Address(Required) Enter Email Confirm Email Preferred Phone Number(Required) DENTAL INSURANCE INFORMATIONDo you have dental insurance?(Required) Yes No Primary Insurance Company(Required)Employee(Required)Relationship(Required)SS #(Required)Employer(Required)Policy #(Required)Birth Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 DENTAL RECORDS RELEASE FORMPrevious Dental Office NameConsent(Required) I hereby give my permission to release any and all of my dental records to Hinke Family Dentistry.Please forward any patient information such as x-rays to Hinke Family Dentistry. Name First Last SignatureDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 HEALTH INFORMATIONPersonal Physician's Name(Required)Have you been hospitalized within the past 2 years?(Required) Yes No If yes, for what?Are you currently being treated by a physician?(Required) Yes No If yes, for what?Are you currently taking any medications or drugs?(Required) Yes No If yes, what?Have you ever received counseling for excessive use of alcohol and/or prescription drugs?(Required) Yes No Are you allergic to any drugs?(Required) Yes No If yes, what?Are you allergic to any metals or latex?(Required) Yes No If yes, what?Do you bleed excessively upon injury?(Required) Yes No Have you used a tooth whitener?(Required) 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.(Required) None AIDS Heart Murmer Heart Problem* Hepatitis Psychiatric Care Sexually Transmitted Diseases Osteoporosis Stroke Tuberculosis Other Diseases Any other diseases? PERSON TO BE CONTACTED IN CASE OF EMERGENCYName(Required)Relationship(Required)Phone Number(Required)
