Welcome Advanced Dental Care of Armonk - Welcome Form 1Patient Information2Primary Insurance3Additional Insurance4Dental History5Medical History6Authorization Name* First Middle Last Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Work PhoneHome PhoneSocial Security #* Email* Age* Birthdate* MM slash DD slash YYYY Gender* Female Male Marital Status Single Married Widowed Separated Divorced Employer Occupation Whom may we thank for referring you? Notify in case of emergency? Primary InsurancePerson responsible for the account?* First Last Relationship to patient? Birthdate MM slash DD slash YYYY Social Security # Address (if different from patient) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Email* Person responsible employed by Occupation Business Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Email PhoneInsurance Company Insurance Company PhoneInsurance Company Email Contract # Group # Subscriber # Name of other dependents under this plan? Is patient covered by additional insurance?* Yes No Subscriber Name* Relationship to patient?* Birthdate MM slash DD slash YYYY Address (if different from patient) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail Subscribed employed by? Business PhoneBusiness Email* Insurance Company PhoneEmail What would you like us to do today?* Are you in dental discomfort today?* Yes No Former Dentist Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Date of last dental care?* MM slash DD slash YYYY Date of last x-rays?* MM slash DD slash YYYY Check if you have had problems with any of the following: Bad breath Food collection between teeth Periodontic treatment Sensitivity to sweets Bleeding Gums Grinding or clenching teeth Sensitivity to cold Sensitivity when biting Clicking or popping jaw Loose teeth of broken fillings Sensitivity to hot Sores or growths in mouth How often do you brush? Floss? How do you feel about the appearance of your teeth? Have you ever experienced an adverse reaction during or in conjunction with a medical or dental proceedure? Other information about your dental health or previous treatment Physician's Name* Phone*Date of last visit* MM slash DD slash YYYY Have you had any serious illness or operations?* Yes No Describe Are you currently under physician care?* Yes No Describe Have you ever had a blood transfusion?* Yes No Describe Have you ever taken Fen-Phen/Redux?* Yes No Have you used bisphosphonate medication? Brand names include Fosomax, Actonel, Atelvia, Didronel and Boniva?* Yes No Women: Are you pregnant? Yes No Nursing? Yes No Taking birth control pills? Yes No Please check if you have had any of the following AIDS/HIV Positive Anaphylaxis Anemia Arthritis,Rheumatism Artificial heart valves Artificial joints Asthma Atopic (allergy prone) Back problems Blood Disease Cancer Chemical dependency Chemotherapy Circulatory problems Cortisone treatments Cough, persistent Cough up blood Diabetes Epilepsy Fainting Food alergies Glaucoma Headaches Heart mumur Heart problems Hemophilia/Abnormal bleeding Herpes Hepatitis High blood pressure Jaw pain Kidney disease or malfunction Liver disease Material allergies (latex, wool, metal, chemicals) Mitral valve prolapse Nervous problem Pacemaker/Heart surgery Psychiatric care Rapid weight gain or loss Radiation treatment Respiratory disease Rheumatic/Scarlet fever Shingles Shortness of breath Skin rash spina Bifida stroke Surgical implant Swelling of feet or ankles Thyroid disease or malfunction Tobacco habit Tonsillitis Tuberculosis Ulcer/Colitis Venereal disease Is patient taking any medications?* Yes No Please list all medications Does patient have any drug allergies?* Yes No Please list all drug allergies* Consent* I agree to the privacy policy.I have recieved the information on this questionairre, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist. I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whetheror not paid by insurance.Signature*
