Dr. Goldfarb's New Patient Forms

Welcome to Our Practice
Please take a few minutes to answer the following questions so we can better assist you with your dental needs.
Today's Date

MonthDayYear
Soc. Sec. #
Birthdate

MonthDayYear
Name

First NameLast Name
Home Phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone

Area CodePhone Number
E-mail
Gender

MaleFemale
Status

MinorSingleMarriedLong Term PartnerDivorcedWidowedSeparated
Employer
Business Phone

Area CodePhone Number
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation
Who should we thank for referring you?
In case of emergency, who should we contact?
Primary Dental Provider
Name of person responsible for account

First NameLast Name
Relationship to patient
Birthdate

MonthDayYear
Soc. Sec. #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Responsible party employed by
Business Phone

Area CodePhone Number
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Subscriber I.D. #
Group #
Additional Insurance
Insured Name

First NameLast Name
Relationship to Patient
Birthdate

MonthDayYear
Soc. Sec. #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Insured Employed by
Business Phone

Area CodePhone Number
Insurance company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Subscriber I.D. #
Group #
Dental History
Former Dentist
City, State
Date of Last X-ray
How often do you floss?
Date of Last Dental Visit
How often do you brush?
Please check all that apply
Medical History
Physician's Name
Date of Last Visit
Are you currently under medical treatment?

YesNo
Have you ever had any serious illnesses or operations?

YesNo
Are you currently taking any medication?

YesNo
Do you smoke?

YesNo
Do you use alcohol, cocaine or drugs?

YesNo
Do you wear contact lenses?

YesNo
Have you had any allergic reactions to the following:

Local Anesthetics (e.g. novocaine)Penicillin or other AntibioticsSulfa DrugsBarbiturates (sleeping pills)SedativesIodineAspirinOther
(Women Only) Are you:

Pregnant?Nursing?Taking birth control pills?
Please check all that apply
Assignment and Payment
I hereby authorize payment directly for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment benefits. I authorize the use of this signature on all insurance submissions.
Signature of Responsible Party*

Clear
Date*

MonthDayYear
Should be Empty:

Welcome to Our Practice

Primary Dental Provider

Additional Insurance

Dental History

Medical History

Assignment and Payment