Pace New Patient Form

Patient Information

Name*

First NameLast Name

Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Cell Phone*

Area CodePhone Number

Home Phone

Area CodePhone Number

SS#/SIN

Birthdate

MonthDayYear

Check Appropriate Box

If College Student, F.T/P.T., Name of School

City

State

Patient's or Parent/Guardian's Employer

Work Phone

Area CodePhone Number

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Spouse or Parent's/Guardian's Name

Employer

Work Phone

Area CodePhone Number

Whom may we thank for referring you?

Person To Contact in Case of Emergency

Phone

Area CodePhone Number

Responsible Party

Name of Person Responsible for This Account

Relationship to Patient

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone

Area CodePhone Number

Diver's License #

Birthdate

MonthDayYear

SS#/SIN

Employer

Work Phone

Area CodePhone Number

Is this person currently a patient in our office?

YesNo

Insurance Information

Name of Insured

First NameLast Name

Relationship to Patient

Birthdate

MonthDayYear

SS#/SIN

Name of Employer

Date Employed

MonthDayYear

Union or Local #

Work Phone

Area CodePhone Number

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Insurance Co.

Tel. #

Area CodePhone Number

GRP#

Policy ID #

Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How much is your deductible?

How much have you used?

Max annual benefit?

Do you have any additional insurance? If yes, complete the following.*

YesNo

Name of Insured

First NameLast Name

Relationship to Patient

Birthdate

MonthDayYear

SS#/SIN

Name of Employer

Date Employed

MonthDayYear

Union or Local #

Work Phone

Area CodePhone Number

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Insurance Co.

Tel. #

Area CodePhone Number

GRP #

Policy ID #

Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How much is your deductible?

How much have you used?

Max annual benefit?

Signature of Patient or Parent/Guardian ir Minor*

Patient Number

Patient Medical History

Patient's Name

First NameLast Name

Date of Birth

MonthDayYear

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 yuo may be taking, could have an important interrelationship with the dentistry that you will be receiving. Check all that apply.

Date of Last Physical Exam

MonthDayYear

Physician's Name

Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Physician's Phone Number

Area CodePhone Number

If yes, please explain.

Women Only

Are you allergic to or have you had reactions to:

If other, please list

Do you have or have you ever had the following?

Patient Dental History

Patient's Name

First NameLast Name

Date of Birth

MonthDayYear

Reason for this visit

When was your last dental visit?

MonthDayYear

What was done then?

How often did you visit the dentist before then?

Previous Dentist (Name and Location)

Have you had a complete series of dental films (X-Rays) taken? When and where?

How often do you brush your teeth?

How often do you floss your teeth?

Is your drinking water fluoridated?

YesNoOther

Check all that apply

If yes, date of placement

If you could change anything about your smile, what would you change?

AUTHORIZATION AND RELEASE:

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third plart payors and/or health practicioners. I authorize and request my insurance company ti oay directly to the dentist or dental group insurance benefits otherwise payable yo me. I understand that my dental insurance carrier may pay less than the actual bill for ervices. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of Patient or Parent/Guardian if Minor

Date

MonthDayYear