Patient Information Form

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:
Address:
Phone:
-
E-mail:
Social Security #:
DL State and #:
Birth Date:
Sex:
Marital Status:
How did you find out about our office/ from whom?:

RESPONSIBLE PARTY/EMERGENCY CONTACT INFORMATION


Contact Name:
Contact Address:
Telephone Number:
-
Cell Phone:
-
Date of Birth:
SSN #:
E-mail Address:

INSURANCE INFORMATION

PRIMARY
Name of Insured:
Insured's DOB:
Insured's Social Security #:
Insured Address:
Insured's Employer:
Employer's Address:
Patient's Relationship to Insured:
Insurance Plan Name:
Plan ID #:
Plan Group #:

SECONDARY

Name-of-Insured:
Insured's-DOB:
Insured's SSN #:
Insured-Address:
Insured's-Employer:
Employer's-Address:
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?
If yes, please explain:
Physicians Name:
Physicians Phone:
Have you ever been hospitalized/operation?
If yes, please explain:
Have you had a serious neck/head injury?
If yes, please explain:
Are you taking any medications; pills or drugs?
If yes, please explain:
Do you take or have you taken Phen-Fen
or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
If yes, please explain:
Do you use tobacco?
If yes, please explain:
Do you use controlled substances?
If yes, please explain:
Women
Are you pregnant, or trying to get pregnant?
Taking Oral Contraceptives?
Nursing?

Are you allergic to any of the following?
Please select any of the following you have had:
Have you been diagnosed with fibromyalgia?
If yes, date of diagnosis:
Have you been diagnosed with Asperger's syndrome?
A learning disability?
ADD/ADHD?
Have you had any serious illness not listed above?
If yes, please explain
Date of Last Dental Visit:
Have you ever had any complications following
dental treatment?
If yes, please explain

Have you ever been told that you need antibiotic coverage prior to dental procedures?
If yes, please explain