Raleigh Cosmetic & Family Dentistry by Morrison & Lloyd, DDS

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Adult New Patient Form

	ABOUT YOU
Last Name	Invalid Input
First Name (*)	Invalid Input
MI (*)	Invalid Input
What You Prefer To Be Called	Invalid Input
Gender (*)	MaleFemale Invalid Input
Birthdate	Invalid Input
Mailing Address (*)	Invalid Input
City (*)	Invalid Input
State (*)	Invalid Input
Zip (*)	Invalid Input
Home Phone #	Invalid Input
Work Phone #	Invalid Input
Ext	Invalid Input
Cell Phone #	Invalid Input
Email Address (*)	Invalid Input
Referred by	Invalid Input
Employer	Invalid Input
How Long?	Invalid Input
Employer Address	Invalid Input
City	Invalid Input
State	Invalid Input
Zip	Invalid Input
Occupation	Invalid Input
Status	MinorSingleMarriedDivorcedSeparatedWidowed Invalid Input
Spouse Name	Invalid Input
Do you have children?	YesNo Invalid Input
How Many?	Invalid Input
	INSURANCE INFO
Primary Dental Insurance Co. Name	Invalid Input
Address
City	Invalid Input
State	Invalid Input
Zip	Please enter valid zip code.
Phone #	Please Enter valid phone number.
Insured's ID#	Invalid Input
Group # (Plan, Local, or Policy #)	Invalid Input
Insured's Name	Invalid Input
Relation	Invalid Input
Date of Birth	Invalid Input
Insured's Employer	Invalid Input
Secondary Dental Insurance Co. Name	Invalid Input
Address	Invalid Input
City	Invalid Input
State	Invalid Input
Zip	Invalid Input
Phone #	Invalid Input
Insured's ID#	Invalid Input
Group # (Plan, Local, or Policy #)	Invalid Input
Insured's Name	Invalid Input
Relation	Invalid Input
Date of Birth	Invalid Input
Insured's Employer	Invalid Input
	IN EVENT OF EMERGENCY
Whom should we contact?	Invalid Input
Relation	Invalid Input
Home Phone #	Invalid Input
Work Phone #	Please enter valid phone number.
Cell Phone #	Please enter a valid phone number.
Who is your Medical Doctor?	Invalid Input
Medical Doctor's Phone #	Please enter a valid phone number.
	DENTAL INFORMATION
Reason for today's visit	ExamEmergencyConsultation Invalid Input
Are you in pain?	NoYes Invalid Input
How Long?	Invalid Input
Please indicate any of the following problems	Discomfort, clicking or popping jaw Red, swollen or bleeding gums. Sensitive tooth, teeth or gums. Blisters/Sores in or around the mouth. Lost/Broken Filling(s) Teeth grinding Ringing in Ears Broken/Chipped tooth Stained teeth Locking Jaw Bad Breath Invalid Input
Others	Invalid Input
Do you require pre-medication?	YesNoDon't know Invalid Input
Previous Dentist	Invalid Input
Phone #	Please enter a valid phone number.
Last Dental Exam	Invalid Input
Last Dental X-Rays	Invalid Input
Times a day you brush?	Invalid Input
Times a week you floss?	Invalid Input
What type of tooth brush bristles do you use?	SoftMediumHard Invalid Input
How would you rate your smile?	Invalid Input
	MEDICAL HISTORY
What medications are you taking?	Nerve pillsPain killer(including aspirin)Muscle relaxersStimulantsBlood ThinnersTranquilizersInsulinMeds for Osteoporosis Invalid Input
Others	Invalid Input
	Have you ever taken:
Bisphosphonates(ex. Aredia/Fosamax)	YesNo Invalid Input
Phen-fen/Redux	YesNo Invalid Input
	Do you have or have you had any of the following diseases, medical conditions or procedures?
Heart Attack/Stroke	YesNo Invalid Input
Heart Surg./Pacemaker	YesNo Invalid Input
Heart Murmur	YesNo Invalid Input
Rheumatic Fever	YesNo Invalid Input
Mitral Valve Prolapse	YesNo Invalid Input
Artificial Valves	YesNo Invalid Input
Heart Disease	YesNo Invalid Input
Congenital Heart Defect	YesNo Invalid Input
Chest Pains	YesNo Invalid Input
Scarlet Fever	YesNo Invalid Input
Nervousness	YesNo Invalid Input
Thyroid Problems	YesNo Invalid Input
Kidney Problems	YesNo Invalid Input
Liver Problems	YesNo Invalid Input
Respiratory Problems	YesNo Invalid Input
Sinus Problems	YesNo Invalid Input
Stomach Problems/Ulcers	YesNo Invalid Input
Psychiatric Problems	YesNo Invalid Input
Venereal Disease	YesNo Invalid Input
Alcohol/Drug Abuse	YesNo Invalid Input
Tuberculosis/TB	YesNo Invalid Input
Jaw Problems TMJ/TMD	YesNo Invalid Input
Cancer/Tumors	YesNo Invalid Input
Shingles	YesNo Invalid Input
Hepatitis	YesNo Invalid Input
HIV+/AIDS/ARC	YesNo Invalid Input
Arthritis/Rheumatism	YesNo Invalid Input
Artificial Bones/Joints	YesNo Invalid Input
Emphysema	YesNo Invalid Input
Fainting/Seizures/Epilepsy	YesNo Invalid Input
Severe/Frequent Headaches	YesNo Invalid Input
Frequent Neck Pain	YesNo Invalid Input
Back Problems	YesNo Invalid Input
Cosmetic Surgery	YesNo Invalid Input
Xray/Cobalt Treatment	YesNo Invalid Input
Chemotherapy	YesNo Invalid Input
Asthma	YesNo Invalid Input
Difficulty Breathing	YesNo Invalid Input
Diabetes/Hypoglycemia	YesNo Invalid Input
Leukemia	YesNo Invalid Input
Anemia	YesNo Invalid Input
High/Low Blood Pressure	YesNo Invalid Input
Bleeding Problems	YesNo Invalid Input
Glaucoma	YesNo Invalid Input
Please list any other surgeries or medical conditions you have or ever had:	Invalid Input
Are you allergic to any of the following?	Latex Penicillin/Amoxicillin Tetracycline Aspirin Dental Anesthetics Invalid Input
Foods	Invalid Input
Others	Invalid Input
Do you use tobacco?	Yes/How used?No Invalid Input
How Much?	Invalid Input
How Long?	Invalid Input
Please rate your general health from 1-10	Invalid Input
Do you wear contacts?	YesNo Invalid Input
	For women
Are you taking Birth Control pills?	YesNo Invalid Input
How many children have you had?	Invalid Input
Are you Pregnant?	YesNo Invalid Input
If yes, How Long?	Invalid Input
Are you nursing?	YesNo Invalid Input
	We invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between provider and patient.
	Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting you account.
	I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance rights.
	I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
Signature (*)	Please write your name to verify the form.
	This constitutes the digital signature. Please enter your name.

Raleigh Cosmetic and Family Dentists

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Morrison & Lloyd DDS

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