New Patient Form

Kimberly Loos, D.D.S. Telephone: 408 985 6779

Family and Cosmetic Dentistry Facsimile: 408 985 6884

4110 Moorpark Avenue, Suite B \n // -->kim@drloos.com

San Jose, CA 95117-1712 http://www.drloos.com/

WELCOME! PLEASE INTRODUCE YOURSELF

Name: ____________________________________________________ Birth Date: ___/___/___

Sex: _____ SS # ______-_____-______

Home Address: __________________________________________________________________

Home Phone: (______)_____________

Street City Zip

Employer: ____________________________________ Occupation: _______________________

Business Phone: (______)___________

Address: ________________________________________________________________________

E-Mail: _________________________

Street City Zip

Drivers License #__________________________________ Married? o Yes o No Fax # (______)__________________

Spouse’s Name: _____________________________________________ Birth Date: ____/____/____

Sex: ____ SS # _____-_____-_____

Employer: ________________________________________ Occupation: ___________________

Business Phone: (______)___________

Address: ________________________________________________________________________

E-Mail: _________________________

Street City Zip

Drivers License #________________________________________________________________

Fax # (______)____________________

Person responsible for account: ___________________________________________________________________________

In case of emergency, please contact: ________________________________________________

Phone: (______)___________________

Whom may we thank for referring you? ____________________________________________________________________

DENTAL INSURANCE

Insured Person’s Name: _______________________________________________

SS # ______-______-_______ Birth Date: ___/___/___

Name of Insurance Company: _____________________________________________________________________________

Address: __________________________________________________________________

Group or Policy # ______________________

Street City Zip

Does your Spouse have separate dental insurance? o Yes o No For Students age 18 and older:

If yes, does this insurance cover you also? o Yes o No School: ______________________

City: ___________

Secondary Insured Person’s Name: ___________________________________________

SS # ____-_____-_____ Birth Date: ___/___/___

Name of Insurance Company: _____________________________________________________________________________

Address: ___________________________________________________________________

Group or Policy # ______________________

Street City Zip

Our office will be glad to fill out and submit your insurance forms as a courtesy to you. However, it is the ultimate responsibility of the

patient to pay for this account.

· A service charge of 1.5% per month (18% per annum) may be charged to accounts exceeding 60 days.

· I give my permission to you or your assigns to telephone me to discuss matters related to this form.

· We kindly request that at least 48 hours advance notice be given to cancel your appointment. There will be a monetary charge for

appointments canceled with less than 48 hours notice.

· We cannot guarantee appointments for patients who arrive more than 15 minutes late.

· I have read the above conditions and I agree with them.

Signature: ____________________________________________________________________ Date: _____/______/_____

DENTAL HISTORY

Previous dentist:_____________________________________________________________________

Phone: (______)______________

Approximate date(s) of last dental care (examination and/or treatment): ________________________

Date of last x-rays: ____/____/___

Have you ever been treated for any of the following:

o Endodontics (root canal) o Prosthodontics (dentures or partials) o Missing teeth

o Orthodontics (tooth movement) o Oral Surgery (extractions/operations) o Existing bridges or crowns

o Periodontics (gum surgery) o Cosmetic Dentistry (whitening, veneers, etc.)

Have you ever had an injury to the face or jaw? o Yes o No

Have you ever had TMJ or CMD (jaw joint) problems? o Yes o No

Are you currently having problems with any of the following:

o Temperature Sensitivity (hot/cold) o Bad Breath (halitosis) o Mouth Breathing

o Pressure Sensitivity (on biting) o Food Impaction o Thumbsucking

o Tender or Bleeding Gums o Clenching/Grinding Teeth o Facial Pain

o Snoring o Other: _____________________________________

MEDICAL HISTORY

Name of Physician or Clinic: ________________________________________________________

Phone: (_____)__________________

How would you describe your general health? o Good o Fair o Poor

Have you seen a physician within the last year? o Yes o No

For what condition(s)? _____________________________________________________________________________________

Have you had a major illness or been hospitalized within the last 5 years? o Yes o No

Please describe: ________________________________________________________________________________________

Are you taking or have you been taking any drugs or medications within the last year? o Yes o No

Please list medications: __________________________________________________________________________________

Have you ever taken phen-fen? o Yes o No

Do you take herbal supplements (Ginseng, Ginko biloba, etc.)? o Yes o No

Please check if you are sensitive to any of the following:

o Penicillin o Novocaine/Lidocaine o Aspirin o Foods

o Other Antibiotics o Codeine o Demerol o Latex

o Sulfa Drugs o Barbiturates (sleeping pills, sedatives) o Other:______________________________

Are you on a special diet or do you have any dietary restrictions? o Yes o No

Please explain:_________________________________________________________________________________________

Do you smoke or use tobacco? o Yes o No

On average, do you consume more than two alcoholic beverages per day? o Yes o No

Have you ever been told you need to be premedicated for a dental appointment? o Yes o No

Have you ever had any of the following:

o Abnormal blood pressure (high/low) o Excessive bleeding o Previous SBE

o HIV or AIDS o Eye Diseases (glaucoma, cataracts, etc.) o Sinus or ear trouble

o Allergy (Hay fever, etc.) o Heart Disease or condition o Surgical Heart Valves

o Anemia o Heart Murmur o Rheumatic Fever

o Angina (chest pains) o Hepatitis, jaundice, liver disease o Severe or frequent headaches

o Artificial transplants or implants o Herpes, cold sores, fever blisters o Respiratory condition

(pacemaker, heart valve, etc.) o Psychiatric care (TB, asthma, emphysema, etc.)

o Arthritis o Joint Replacement (hip, knee, etc.) o Skin Disease

o Blood transfusions o Kidney Disease or disorder o Stroke

o Cancers, tumors, malignancies o Nervous Disorder o Thyroid condition (high/hypo)

o Congenital Heart Defects o Mitral Valve Prolapse o Ulcers

o Diabetes o Mitral Regurgitation o Venereal Disease (syphilis, gonorrhea, etc.)

o Epilepsy o Parkinson’s Disease o X-ray, radium, cobalt treatment(s)

Is there any other information about your health that we should know? _______________________________________________

WOMEN ONLY: Are you pregnant? o Yes o No Expected Delivery Date: ______/______/______

Are you taking oral contraceptives? o Yes o No

Are you in or have you passed through menopause? o Yes o No

Patient Signature: ______________________________________________________________ Date: ______/_______/______

CUSTOMIZING YOUR TREATMENT PLAN

I am most interested in:

o Cosmetic options o Maintaining general oral health o Children’s dentistry

o Controlling gum disease o Pain reduction o Other________________________________________

I place the highest dental value on:

o Appearance o Comfort o Longevity

o Function o Cost effectiveness

Most of my dental decisions are based on:

o Cost o Appearance

o Health o Fear

Please share your hobbies or interests with us: ______________________________________________________________________________

(For Dentist Use Only)

INFORMATION UPDATES

BP_____/_____ Date: _____/_____/_____

Has this patient had any changes in health status since their last dental visit (i.e. illness, allergies, hospitalization, medications, etc.)?

Date Comments Date Comments

______________________________________________________________________________________________________