New Patient Forms | Alan Mauldin, DDS

Let us see those pearly whites

We are excited you have chosen to become a patient! We need to get to know you a little more, please complete our new patient form. You can submit the form by either:

Download the form here in Adobe PDF format, complete and bring with you to your appointment

-OR-

Complete the online form below and submit when completed

Online Patient Information Form

PATIENT INFORMATION

Date

Patient Last Name

First Name

Middle Initial

Street Address

City

State

Zip

Patient Email

Sex

Patient Employer/School

Age

Date of Birth

Occupation

Employer/School Address

Employer/School Phone

Marital Status:

Married

Widowed

Single

Separated

Divorced

Minor

Partnered for ___ years

How many years?

Spouse's Name

Date of Birth

SS#

Spouse's Employer

Home Phone

Work Phone

Cell Phone

Spouse's Work Phone

Best time and place to reach you

EMERGENCY CONTACT

Name

Home Phone

Relationship

Work Phone

DENTAL INSURANCE

Who is responsible for this account?

Insurance Company

Relationship to Patient

Group Number

Is patient covered by additional insurance?

Yes

Subscriber's Name

Date of Birth

SS#

Relationship to Patient

Insurance Company

Group Number

ASSIGNMENT & RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

Insurance Company

and

assign directly to Dr.

Doctor's Name

all insurance benefits, if any, otherwise payable to me

for services rendered. I understand that I am financially responsible for all charges 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(ees) 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

Name of Patient, Parent, Guardian or Personal Representative

Date

Relationship to Patient

DENTAL & MEDICAL HISTORY

Although dental personnel 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 medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions pertaining both your dental and medical history.

Reason for today's visit

Former Dentist

Date of last dental visit

City/State

Date of last dental X-rays

PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING:

Bad breath

YES

Bleeding gums

YES

Blisters on lips or mouth

YES

Cigarette, pipe or cigar smoking

YES

Clicking or popping jaw

YES

Dry mouth

YES

Burning sensation on tongue

YES

Fingernail biting

YES

Chew on one side of mouth

YES

Food collection between teeth

YES

Foreign objects

YES

Lip or cheek biting

YES

Orthodontic treatment

YES

Sensitivity to heat

YES

Grinding teeth

YES

Loose teeth or broken fillings

YES

Pain around ear

YES

Sensitivity to sweets

YES

How often do you floss?

Gums swollen or tender

YES

Mouth breathing

YES

Periodontal treatment

YES

Sensitivity when biting

YES

Jaw pain or tiredness

YES

Mouth pain, brushing

YES

Sensitivity to cold

YES

Sores or growths in your mouth

YES

How often do you brush?

Women, are you:

Pregnant/trying

Nursing

Taking oral contraceptives

Are you allergic to any of the following:

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Other

If other, please specify:

Are you under a physician's care now?

YES

If yes:

Are you taking any pills, medication or drugs?

YES

If yes:

Are you on a special diet?

YES

Have you ever been hospitilized or had a major operation?

YES

If yes:

Do you take, or have taken, Phen-Fen or Redux?

YES

If yes:

Have you ever had a serious head or neck injury?

YES

If yes:

Have you ever taken Fosamax, Boniva, Actonel or any other medication containing bisphosphonates?

YES

If yes:

Do you use tobacco?

YES

Do you use controlled substances?

YES

If yes:

DO YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING?

AIDS/HIV Positive

YES

Alzheimer's Disease

YES

Anphylaxis

YES

Anemia

YES

Angina

YES

Arthritis/Gout

YES

Artificial Heart Valve

YES

Artificial Joint

YES

Asthma

YES

Blood Pressure

YES

Blood Transfusion

YES

Breathing Problems

YES

Bruise Easily

YES

Cancer

YES

Chemotherapy

YES

Chest Pains

YES

Cold Sores/Fever Blisters

YES

Congenital Heart Disorder

YES

Convulsions

YES

Cortisone Medicine

YES

Diabetes

YES

Drug Addiction

YES

Easily Winded

YES

Emphysema

YES

Epilepsy or Seizures

YES

Excessive Bleeding

YES

Excessive Thirst

YES

Fainting Spells/Dizziness

YES

Frequent Cough

YES

Frequent Diarrhea

YES

Frequent Headaches

YES

Genital Herpes

YES

Glaucoma

YES

Hay Fever

YES

Heart Attack/Failure

YES

Heart Murmur

YES

Heart Pacemaker

YES

Heart Trouble/Disease

YES

Hemophilia

YES

Hepatitis A

YES

Hepatitis B or C

YES

Herpes

YES

High Blood Pressure

YES

High Cholesterol

YES

Hives or Rash

YES

Hypoglycemia

YES

Irregular Heartbeat

YES

Kidney Problems

YES

Leukemia

YES

Liver Disease

YES

Low Blood Pressure

YES

Lung Disease

YES

Mitral Valve Prolapse

YES

Osteoporosis

YES

Pain in Jaw Joints

YES

Parathyroid Disease

YES

Psychiatric Care

YES

Radiation Treatments

YES

Recent Weight Loss

YES

Renal Dialysis

YES

Rheumatic Fever

YES

Rheumatism

YES

Scarlet Fever

YES

Shingles

YES

Sickle Cell Disease

YES

Sinus Trouble

YES

Spina Bifida

YES

Stomach/Intestinal Disease

YES

Stroke

YES

Swelling of Limbs

YES

Thyroid Disease

YES

Tonsillits

YES

Tuberculosis

YES

Tumors or Growths

YES

Ulcers

YES

Venereal Disease

YES

Yellow Jaundice

YES

Have you ever had any serious illness not listed above?

YES

If yes:

Comments

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent, Guardian or Personal Representative

Date

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT & PATIENT CONSENT FORM

I understand, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health/dental information. I understand this information can and will be used to:

Conduct, plan and direct my treatment and follow up among multiple healthcare providers who may be involved in my treatment directly and/or indirectly.
Conduct normal healthcare operations, such as physician certifications and assessments.
Obtain payment from third party payers, such as insurance companies.
Confirm and leave messages at phone numbers provided to this office.

I have been informed of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at anytime to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or dental care operations. I also understand you are not required to agree to my restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name

Relationship to Patient

Additional family members given access

Signature

Date

Thanks for submitting!

Let us see those pearly whites

Online Patient Information Form

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