Welcome to Gilbert Smiles
We are pleased to welcome you to our practice. Please take a few minutes to fill out
this form as completely as you can. If you have any questions we'll be glad to help you.
We look forward to working with you in maintaining your dental health.

Name____________________________________________________________Soc. Sec. #___________________________________
  Last Name First Name Initial
Address_____________________________________________Home Phone____________________Cell Phone___________________
City_________________________________State______________Zip________________Email________________________________
Sex MF Age_______Birthdate_____________ Single Married Widowed Separated Divorced
Patient Employed by_____________________________________________Occupation_____________________________________
Business Address ______________________________________________Business Phone__________________________________
Whom may we thank for referring you?____________________________________________________________________________
Notify in case of emergency__________________________Home Phone__________________Work Phone____________________
Cell Phone___________________________

PRIMARY INSURANCE
Person Responsible for Account___________________________________________________________________________________
Last Name First Name Initial
Relation to Patient________________________________Birthdate______________________Soc. Sec.#_______________________
Address (if different from patient)________________________________________________Home Phone_____________________
Cell Phone______________________________________ Email__________________________________________________________
City______________________________________________ State___________________________ Zip__________________________
Person Responsible Employed by_____________________________________Occupation__________________________________
Business Address ______________________________________________Business Phone__________________________________
Insurance Company ____________________________________________________________________________________________
Contract #_______________________ Group #____________________________Subscriber#________________________________
Name of other dependents under this plan________________________________________________________________________

ADDITIONAL INSURANCE
Is patient covered by additional insurance? YN
Subscriber Name___________________________ Relation to Patient_________________________Birthdate_________________
Address (if different from patient)________________________________________________Soc. Sec. #_____________________
City_________________________ State_________________ Zip_________________ Home Phone___________________________
Cell Phone ______________________________ Business Phone_______________________________________________________
Subscriber Employed by ________________________________________________________________________________________
Insurance company_____________________________________ Phone_________________________________________________
Contract #_______________________ Group #____________________________Subscriber#_______________________________
Name of other dependents under this plan_______________________________________________________________________

Please be sure to complete both parts of the form

DENTAL HISTORY

What would you like us to do today?________________________________________ Are you in discomfort today?_______________
Former Dentist__________________________ Address_______________________________________ Phone______________________
Date of last dental care___________________________________ Date of last X-rays_________________________________________
Check Y for yes or N for no if you have/have not had the following:
Y N Bad Breath
Y N Bleeding gums
Y N Clicking or popping jaw
Y N Food collection between teeth
Y N Grinding or clenching teeth
Y N Loose teeth or broken fillings
Y N Periodontal treatment
Y N Sensitivity to cold
Y N Sensitivity to hot
Y N Sensitivity to sweets
Y N Sensitivity when biting
Y N Sores or growths in mouth
How often do you brush?_______________________________ How often do you floss?________________________________________
How do you feel about the appearance of your teeth on a scale of 1 to 5?
1 (Bad)
2
3
4
5(Great)
Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?
Y
N
MEDICAL HISTORY
Physician's Name____________________________ Address_____________________________________ Phone_______________
Date of last visit______________Have you had any serious illness or operations?
Y N If yes, describe______________________
Are you currently under physician care? YN If yes, describe_________________________________________________________
Have you ever had a blood transfusion? YN If yes, describe_________________________________________________________
Women: Are you pregnant? YN Nursing? YN Taking birth control pills? YN
Check Y for yes or N for no if you have/have not had the following:
YN AIDS
YN Anaphylaxis
YN Anemia
YN Arthritis, Rheumatism
YN Artificial heart valves
YN Artificial joints
YN Asthma
YN Atopic (allergy prone)
YN Back problems
YN Blood disease
YN Cancer
YN Chemical dependency
YN Chemotherapy
YN Circulatory problems
YN Cortisone treatments
YN Cough, persistent
YN Cough up blood
YN Diabetes
YN Epilepsy
YN Fainting
YN Food allergies
YN Glaucoma
YN Headaches
YN Heart murmur
YN Heart problems
Describe________________
YN Hemophilia/Abnormal
Bleeding
YN Herpes
YN Hepatitis
YN High blood pressure
YN HIV positive
YN Jaw pain
YN Kidney disease or
malfunction
YN Liver disease
YN Material allergies
(latex, wool, metal, chemical)
YN Mitral valve prolapse
YN Nervous problems
YN Pacemaker/Heart Surgery
YN Psychiatric care
YN Rapid weight gain or loss
YN Radiation treatment
YN Respiratory disease
YN Rheumatic fever
YN Scarlet fever
YN Shingles
YN Shortness of breath
YN Skin rash
YN Spina Bifida
YN Stroke
YN Surgical implant
YN Swelling of feet or ankles
YN Thyroid disease or
malfunction
YN Tobacco habit
YN Tonsillitis
YN Tuberculosis
YN Ulcer/Colitis
YN Veneral disease
List medications you are currently taking, if any:
_____________________________________________________
_____________________________________________________
List drug allergies, if any:
_____________________________________________________
_____________________________________________________
AUTHORIZATION

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered.
I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature__________________________________________________________________________Date_________________________

Payment is due in full at time of treatment unless prior arrangements have been approved.