Patient Information Form

Please fill out the below form before your visit. All information is encrypted and complies with HIPPA standards. You are not required to give your social security number. If you have any questions, please call us 262.657.5408.

Patient Information

Date:

Telephone:

Alternate Phone:

Last Name:

First Name:

Middle Initial:

SS/HIC/Patient ID #:

Address:

Email:

City:

State:

Zip Code:

Sex: MF

Age:

Birthdate:

Patient Employer/School :

Occupation:

Employer/School Address:

Employer/School Phone:

Whom may we thank for referring you?

In case of emergency who should be notified:

Phone:

Primary Insurance

Person Responsible for Account :

Last Name :

First Name

Middle Initial

Relation to Patient:

Birthdate:

ID#/SSN

Address (if different from patient's):

Phone:

City:

State:

Zip:

Person Responsible Employed By:

Occupation:

Business Address:

Business Phone:

Insurance Company:

Contract #:

Group #:

Subscriber Number:

Names of other dependents covered under this plan:

Additional Insurance

Is patient covered by additional insurance? YesNo

Subscriber Name :

Relation to Patient

Birthdate

Address (if different from patient's):

Phone:

City:

State:

Zip:

Subscriber Employed By:

Business Phone:

Insurance Company:

SSN:

Contract #:

Group #:

Subscriber Number:

Names of other dependents covered under this plan:

Dental History

Reason for Today's Visit

Date of last dental care

Former Dentist

Date of last dental x-rays

Address

Check if you have had problems with any of the following:

Bad breathBleeding gumsClicking or popping jawGrinding teethSensitivity to hotLoose teeth or broken fillingsPeriodontal treatmentSensitivity to sweetsSensitivity when bitingFood collection between teethSensitivity to coldSores or growths in your mouth

 

How often do you floss? How often do you brush?

Medical History

Physician's Name:

Date of Last Visit:

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. YesNo

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 (fenfluramine) and Redux (dexfenfluramine). YesNo

Have you had any serious illnesses or operations? YesNo If yes, describe

Have you ever had a blood transfusion? YesNo If yes, give approximate dates

(Women) Are you pregnant? YesNo Nursing? YesNo Taking birth control pills? YesNo

Check if you have or have had any of the following:

AnemiaCortisone TreatmentsArthritis, RheumatismCough, PersistentArtificial Heart ValvesCough up BloodArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

 

MEDICATIONS: List medications you are currently taking:

ALLERGIES:

Authorization

I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. Fulmer 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(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.