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Sample new patient questionnaire

Durrell “Buddy” Smith, D.D.S.
Kyle M. Smith, D.D.S.
- Family Dentistry -
Patient Information
Chart # (For Office Use Only) _____________________ Patient Name: ____________________________________________________________ Date ________________ Last First MI (Preferred Name) Male Female Married Single Child Other _____________ Birth Date:____/____/________ Social Security #: _______-_____-________ E-Mail Address: _______________________________ Best time to call: __________________ Phone (Home): ___________________ (Work): ___________________ (Mobile):_____________________ Address: __________________________________________________________________________________ __________________________________________________________________________________ Spouse or Responsible Party Information
Last First MI (Preferred Name) Male Female Married Single Child Other Birth Date:____/____/________ Social Security #: _______-_____-________ Phone (Home): ________________ (Work): ________________ Ext:______ Best time to call: Employment Information
Employer Name: ______________________ Occupation: ____________________ Phone: ________________ Referral Information
Whom may we thank for referring you to our practice? Another patient, friend Another patient, relative Internet Dental Office Yellow Pages Newspaper School Work Other____________ Name of person or office referring you to our practice:_____________________________________________________ Insurance Information

Primary Insurance
Name of Insured: _______________________________________________ Is insured a patient? Yes No
Last First MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Street City State Zip Code Insured's Employer Name: Street City State Zip Code Patient's relationship to insured: Self Spouse Child Other___________________
Secondary Insurance

Name of Insured: _______________________________________________ Is insured a patient? Yes No
Last First MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Street City State Zip Code Patient's relationship to insured: Self Spouse Child Other___________________ Medical & Dental History

Would you consider yourself to be in fairly good health? Yes No
Within the past year, have there been any changes in your general health? Yes No
What is the date (or approximate date) of your last medical exam? ______________________________
Your Primary Care Physician’s name & phone number: _______________________________________

Please mark the following Yes or No:
Yes No
Are you currently under the care of physician due to a specific condition?
Have you been hospitalized within the last 5 years due to a surgery or illness?
Do you use tobacco (smoking or chewing)?
If any of the previous questions are marked yes, please explain:
Are you currently taking any prescription or non-prescription medications? (Please list below)

Please indicate if you have experienced any of the following:

Do you have any other health issues or known drug allergies not listed above that we should be aware of?
Woman Only: Are you pregnant? Yes No If yes, when is the due date? ___________________
What is the reason for your dental visit today? ______________________________________________
When was your last visit to the dentist (if at a different office)? __________________________________
What treatment was performed on your last dental visit (if at a different office)? _____________________
Prior Dentist’s name, address, & phone number: _____________________________________________
How frequently do you brush your teeth?
3 (+) a day Twice a day Once a day Weekly Seldom
How frequently do you floss your teeth?
1 (+) a day 2-6 weekly 1-6 monthly Seldom Never

Please mark the following Yes or No:
Yes No
Have you ever had complications following dental treatment?
Are any of your teeth currently causing you pain or discomfort?
Are you extremely apprehensive with dental treatment?
Do you frequently consume sugar in drinks, hard candy, or chewing gum?
Do you grind your teeth either consciously or during sleep (day or night)?
Do you have headaches or neck pains during the day or night?
Do you have pain, clicking, or popping in the jaw joint?
If you marked Yes to any of the previous questions, please explain if needed:
Consent for Services at Durrell P. Smith, D.D.S. & Kyle M. Smith, D.D.S.

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the
patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services
are performed.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally
responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance
companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our
charges will be paid by an insurance company.
A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously
written financial arrangements are satisfied.
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said
services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree
that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that
a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs
and reasonable attorney fees if suit be instituted hereunder.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

____________________________________________________ Date: _____________ Relationship to Patient:
Signature of patient, parent or guardian ____________________________________________________ Date: _____________ Relationship to Patient: Signature of guarantor of payment/responsible party

Source: http://smithdentistry.net/yahoo_site_admin/assets/docs/New_Patient_Form317144311.32264636.pdf

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