Patient Form | Dentist Alexandria | Family Dentistry

Fill out and submit the form below at the convenience of your computer or download the forms at the link below and mail them to the appropriate office.

Patient Information:

Today's Date:

Patient's Name:

Social Security Number:

Gender:

Age:

Birthdate:

Email Address:

Marital Status:

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Other Phone:

Employer:

Occupation:

Length of Employment:

Best time to reach you?

Pager:

Whom may we thank for referring you to our office?

Spouse's Name:

Spouse's Social Security Number:

Spouse's Birthdate:

Spouse's Employer:

Spouse's Occupation:

Spouse's Work Phone:

Dentist:

Other family members seen by us:

Person Responsible for Account:

Name:

Social Security Number:

Relationship to Patient:

Home Phone:

Employer:

Work Phone:

Address:

City:

State:

Zip Code:

Primary Insurance:

Dental Insurance:

Insured's Name:

Insured's Social Security Number:

Insurance Company:

Insurance Co. Address (1):

Insurance Co. Address (2):

Insurance Co. City:

Insurance Co. State:

Insurance Co. Zip:

Phone Number

Group No.

Insured's Employer:

Birthdate:

Relationship to Patient:

Medical History

Have you Ever had:

General Health:

Epilepsy:

Heart Problems:

Respiratory Disease:

Stroke:

High or Low Blood Pressure:

Thyroid Trouble:

Sinus Problems:

Leukemia:

Liver problems:

Circulator problems:

Numbness or tingling:

Dizziness:

Nervous problems:

Mental problems:

Excessive or prolonged bleeding:

Convulsions:

Anemia:

Aids or HIV infection:

Arthritis:

A Physical Handicap:

Asthma:

Blood Abnormalities:

Rheumatic Fever or Heart Murmer:

Mitral Valve Prolapse:

Diabetes:

Tuberculosis:

Hepatitis:

Malignancies:

Stomach Ulcers:

Are you taking any medications?

If so, list them:

Are you being treated for anything now?

Have you been within the last 5 years?

Are you Pregnant?

Have you ever had radiation or X-ray therapy?

Have you ever taken cortisone or thyroid medication?

Are you taking birth control pills?

Are you taking Acetaminophen?

List any drugs, food or medication you are allergic or sensitive to:

Online Patient Form

Patient Information:

Person Responsible for Account:

Primary Insurance:

Medical History

Questions? Get in Touch

Find Us

Resources