Mdvdental.com

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 questions we’ll be glad to help you.
We look forward to working with you in maintaining your dental health.
Date __________________________ Home Phone ( ) _____________________ Cell Phone ( ) ______________________________Name _________________________________________________________________ Social Security # ________________________________ Address _______________________________________________________________ E-mail_________________________________________ mation City __________________________________________________________________ State________ Zip __________________________ or Sex  M  F Age _______Birthdate_____________________________________  Married  Widowed  Single  Minor  Seperated  Divorced  Partenered for _____ Years Patient Employer / School _________________________________________________ Occupation________________________________ Employer/School Address _________________________________________________ Employer/School Phone ( )________________ Whom may we thank for referring you? _____________________________________ Patient Inf In case of emergency who should be notified? _______________________________ Phone ( ) __________________________________ Person Responsible for Account ___________________________________________________________________________________________ Relation to Patient _______________ Birthdate _______________________ Social Security # _______________________________________ Address (If different from patient’s) __________________________________ Phone ( ) ________________________________________ City ___________________________________________________________ State________ Zip _____________________________ Person Responsible Employed by ___________________________________ Occupation ___________________________________________ y Insurance Business Address ________________________________________________ Business Phone ( ) _________________________________ Insurance Company ____________________________________________________________________________________________________ Primar Contract # _________________________Group # _____________________ Subscriber # __________________________________________ Names of other dependants covered under this plan __________________________________________________________________________ Date __________________________ Home Phone ( ) ______________________ Cell Phone ( ) _______________________________Name _________________________________________________________________ Social Security # ________________________________ Address _______________________________________________________________ E-mail_________________________________________ City __________________________________________________________________ State________ Zip __________________________Sex  M  F Age _______Birthdate_______________________________  Married  Widowed  Single  Minor  Seperated  Divorced  Partenered for _____ Years Patient Employer / School _________________________________________________ Occupation________________________________ Employer/School Address _________________________________________________ Employer/School Phone ( )________________ Whom may we thank for referring you? _____________________________________ dditional Insurance In case of emergency who should be notified? _______________________________ Phone ( ) __________________________________ MDV Dental • 1150 N Hudson • Lowell, MI • 49331 • (616) 897-8429 www.mdvdental.com
Reason for Today’s Visit ___________________________________________ Date of last dental care __________________________________ y Former Dentist _________________________________________________ Date of last dental x-rays _________________________________ Address ______________________________________________________________________________________________________________Check (  ) if you had problems with any of the following:  Loose teeth or broken fillings  Sensitivity to sweets  Food collection between teeth  Sensitivity to cold Physician’s Name ___________________________________________ Date of Last Visit ____________________________________________ Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.  Yes  No Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimin, Adipex, Fastin(brand names of phentermine), Pondimin (fenfluramone) and Redux (dexfenfluramine).  Yes  No Do you consume more than 2 or 3 alcoholic beverages per day?  Yes  No Have you had any serious illnesses or operations?  Yes  No If yes, describe _________________________________________________Have you ever had a blood transfusion?  Yes  No If yes, give approximate date(s) ___________________________________ y (Women) Are you pregnant  Yes  No Nursing?  Yes  No Taking birth control pills  Yes  No Check (  ) if you had problems with any of the following: MEDICATIONS: List medications you are currently taking: _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ I certify that I, and/or my dependant(s), have insurance coverage with __________________________________________ and assign directly to Dr. _____________________________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
_______________________________________________________________________________ ___________________________________ Signature of Patient, Parent, Guardian or Personal Representative A _______________________________________________________________________________ ___________________________________ Please print name of Patient, Parent, Guardian or Personal Representative Payment if due in full at the time of treatment unless prior arrangements have been approved.
MDV Dental • 1150 N Hudson • Lowell, MI • 49331 • (616) 897-8429 www.mdvdental.com

Source: http://www.mdvdental.com/forms/MDVDentalNewPatientForm.pdf