New Patient Forms PATIENT INFORMATIONPatient's Name*Preferred name*Birth date* If minor, parents namesHome PhoneWork PhoneMobile phone*Mailing address* Street Address City State / Province / Region ZIP / Postal Code EmployerOccupation*Spouse's nameSpouse's employerMarried / Unmarried*MarriedUnmarriedEMERGENCY CONTACTName*Home/mobile phone*HOW DID YOU HEAR ABOUT US?Please choose* Friend/Family Yelp Google Facebook YouTube Other Please tell us who so we can thank them*PREFERRED PHARMACYNameAddressBILLING, CREDIT, AND INSURANCE INFORMATIONCovered by dental insurance*YesNoYour Social Security numberDental Insurance Co.*Group #*Member #*Covered by spouse’s insurance?*YesNoSpouse’s Social Security numberSpouse’s Date of Birth* Dental Insurance Co.*Group #*Member #*MEDICAL HEALTH HISTORYAre you under a physician’s care right now?*YesNoIf yes please explainHave you ever been hospitalized or have had a major operation?*YesNoIf yes please explainHave you ever had a serious head or neck injury?*YesNoIf yes please explainAre you taking any medications, pills, or drugs?*YesNoIf yes please explainDo you taken, or have you taken, Phen-Phen or Redux?*YesNoIf yes please explainAre you on a special diet?*YesNoIf yes please explainDo you smoke or use tobacco?*YesNoDo you have or have you had any of the following? (Please check any that apply) Cancer or tumor Heart ailment or angina Heart murmur, mitral valve prolapse, heart defect Rheumatic fever or rheumatic heart disease Artificial joint or valve High or low blood pressure Pacemaker Tuberculosis or other lung problems Kidney disease Hepatitis or other liver disease Alcoholism Blood transfusion Diabetes Neurologic condition Epilepsy, seizures, or fainting spells Emotional condition Arthritis Herpes or cold sores AIDS or HIV positive Migraine headaches or frequent headaches Anemia or blood disorders Abnormal bleeding after extractions, surgery, or trauma Hayfever or sinus trouble Allergies or hives Asthma Are you allergic to, or have you reacted adversely to any of the following? (Please check any that apply) Latex materials Penicillin or other antibiotics Local anesthetics ("Novocain") Codeine or other narcotics Sulfa drugs Barbiturates, sedatives, or sleeping pills Aspirin Other AllergiesAre you taking any of the following? (Please check any that apply) Aspirin Anticoagulants (blood thinners) Antibiotics or sulfa drugs High blood pressure medicine Antidepressants or tranquilizers Insulin, Orinase, or other diabetes drug Nitroglycerin Cortisone or other steroids Osteoporosis (bone density) medicine Other Drugs or MedicationsFOR WOMENPregnant/Trying to get pregnant? Expected delivery dateTaking hormones or contraceptives?YesNoOTHER INFORMATIONYour Primary Physician Name:PhoneDo you have any disease, condition, or problem not listed above? Please describePlease add anything else you would like us to know about:SIGNATURETo the best of my knowledge, the questions on this form have been accurately answered. I understand that by providing incorrect information to my (or patient’s) health. It is my responsibility to inform THE SCIENCE OF SMILES® about any changes to my medical status.*I agree with all of the aboveSIGNATURE OF PATIENT, PARENT, OR GUARDIANEmail To Receive A Copy Of This Form* Date: 01/23/2019 This iframe contains the logic required to handle Ajax powered Gravity Forms.