Patient Information Form - Palmetto Family Dentistry

Please complete the form in its entirety, and click the submit button. Your confidential information will be securely submitted to Palmetto Family Dentistry. Upon your visit to our office, you will need to complete and sign the signature page. If you have any additional questions or comments, please feel free to contact us.

		
		
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
          PATIENT INFORMATION

Name: 
First Last
Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
Phone: - 
Area Code Phone Number
E-mail: 
Social Security #: 
DL State and #: 
Birth Date: 
Sex: Male Female
Marital Status: Married Single Child
How did you find out about 
our office/ from whom?: 
RESPONSIBLE PARTY/EMERGENCY CONTACT INFORMATION 

Contact Name: 
First Last
Contact Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
Telephone Number: - 
Area Code Phone Number
Cell Phone: - 
Area Code Phone Number
Date of Birth: 
SSN #: 
E-mail Address: 
INSURANCE INFORMATION 
PRIMARY
Name of Insured: 
First Last
Insured's DOB: 
Insured's Social Security #: 
Insured Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
Insured's Employer: 
Employer's Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
Patient's Relationship to Insured: 
Insurance Plan Name: 
Plan ID #: 
Plan Group #: 
SECONDARY
Name-of-Insured: 
First Last
Insured's-DOB: 
Insured's SSN #: 
Insured-Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
Insured's-Employer: 
Employer's-Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry
Patient's-Relationship to Insured: 
Insurance-Plan-Name: 
ID #: 
Group #: 
PATIENT'S HEALTH INFORMATION 
Although we primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medicines that you may be taking, could have an important interrelationship with the dentistry that you will receive. Thank you for TRUTHFULLY answering the following questions.
Are you under a physcians care? yes no
If yes, please explain: 
Physicians Name: 
Physicians Phone: 
Have you ever been hospitalized/operation? yes no
If yes, please explain: 
Have you had a serious neck/head injury? yes no
If yes, please explain:  
Are you taking any medications; pills or drugs? yes no
If yes, please explain:   
Do you take or have you taken Phen-Fen 
or Redux? yes no
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? yes no
Are you on a special diet? yes no
If yes, please explain:    
Do you use tobacco? yes no
If yes, please explain:     
Do you use controlled substances? yes no
If yes, please explain:      
Women
Are you pregnant, or trying to get pregnant? yes no
Taking Oral Contraceptives? yes no
Nursing? yes no
Are you allergic to any of the following? Asprin Latex Penicillin
Acrylic Local Anesthetics Sulfa Drugs
Codeine Metal Other
Please select any of the following you have had:
AIDS/HIV Positive Cortison Medicine Hemophilia Radiation Treatments
Alzheimer's Disease Diabetes Hepatitis A Recent Weight Loss
Anaphylaxis Drug Addiction Hepatitis B or C Renal Dialysis
Anemia Easily Winded Herpes Rheumatic Fever
Angina Emphysema High Blood Pressure Rheumatism
Arthritis/Gout Epilepsay Seizures High Cholesterol Scarlet Fever
Artificial Heart Valve Excessive Bleeding Hives or Rash Shingles
Artificial Joint Excessive Thirst Hypoglycemia Sickle Cell Disease
Asthma Fainting Spells/Dizziness Irregular Heartbeat Sinus Trouble
Blood Disease Frequent Cough Kidney Problems Spina Bifida
Blood Transfusion Frequent Diarrhea Leukimia Stomach/Intestinal Disease
Breathing Problem Frequent Headaches Liver Disease Stroke
Bruise Easily Genital Herpes Low Blood Pressure Swelling of Limbs
Cancer Glaucoma Lung Disease Thyroid Disease
Chemotherapy Hay Fever Mitral Valve Prolapse Tonsillitis
Chest Pains Heart Attack/Failure Osteoporosis Tuberculosis
Cold Sores/Fever Blisters Heart Murmur Pain in Jaw Joints Tumors or Growths
Congenitial Heart Disorder Heart Pacemaker Parathyroid Disease Ulcers
Convulsions Heart Trouble Disease Psychiatric Care Venereal Disease
Yellow Jaundice
Have you been diagnosed with fibromyalgia? yes no
If yes, date of diagnosis: 
Have you been diagnosed with Asperger's syndrome? yes no
A learning disability? yes no
ADD/ADHD? yes no
Have you had any serious illness not listed above? yes no
If yes, please explain         
Date of Last Dental Visit: 
Have you ever had any complications following 
dental treatment? yes no
If yes, please explain          
Have you ever been told that you need antibiotic coverage prior to dental procedures? yes no
If yes, please explain            
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