Form - R. Paul Campbell, D.M.D.

Name *

First

Last

Gender

Male
Female

Social Security Number

Birthdate

Home Address

City

State

Zip

Primary Phone Number

Primary Phone

Home
Cell
Other

Secondary Phone Number

Secondary Phone

Home
Cell
Other

Email Address

Employer / School

Marital Status

Emergency Contact Name

Emergency Contact Relationship

Phone Number

Address

Primary Insurance Company

Insurance Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relationship to patient

Policy Holder's Social Security Number

(if different from patient)

Policy Holder's Birth Date

(if different from patient)

Employer

Work Phone Number

General Dentist Name

Last Dental Visit

How did you hear about our Practice?

Name of person referring

(if applicable)

Reason for the consultation

Have you visited an orthodontist before?

Yes
No

When?

Reason?

Have your tonsils or adenoids been removed?

Yes
No

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Yes
No

Do you have any missing or extra permanent teeth?

Yes
No

Have you ever had an injury to (select all that apply):

Teeth
Mouth
Chin

Do you have speech problems?

Yes
No

If so, explain:

Do your gums bleed?

Yes
No

Do you smoke?

Yes
No

Do you like your smile?

Yes
No

Do you currently or have you ever had any of the following habits?

Are you currently being treated by a physician?

Yes
No

Reason

Physician

Phone

Do you have any allergies/sensitivities to medications or latex?

Yes
No

If yes, please list allergies:

Are you currently taking any prescription or over-the-counter medications?

Yes
No

If yes, please list with dosage:

Have you ever taken any Bisphosphonate medications for osteoporosis? (ex: Boniva, Fosomax, Actonel, Reclast)

Yes
No

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

Have you ever had a blood transfusion?

Yes
No

If yes, give approximate dates:

Are you pregnant?

Yes
No

Nursing?

Yes
No

Taking birth control pills?

Yes
No

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

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Patient Signature and/or Responsible Party

Date