Patient Forms | Teche Dental

Patient Forms

We're excited to meet you! Please take a few minutes to fill out our New Patient Form. You can fill out the online form to the right, or you can click here to download a PDF of our forms.

If you have any questions, we're happy to help you! Just contact our office.

Please note that this form does time out after 20 minutes, please complete in one sitting.

NEW PATIENT INFORMATION

Title First Name Last Name Date Address City State ZipCode Country Home Phone Number Work Phone Number Mobile Phone Number Email Sex Birthdate Marital Status Employer Work Address City State Zip code Occupation Whom may we thank for referring you to our office? In case of emergency who should be notified? Emergency Contacts Phone Number

RESPONSIBLE PARTY

Person Responsible for payment Relation to patient Responsible party's birthdate Responsible party's address (if different from patient) Responsible party's City Responsible party's State Responsible party's Zipcode Responsible party's Phone Number Insurance Company Contract Group Subscriber #

SECONDARY INSURANCE

Subscriber Name Relation to patient Subscriber's Birthdate Subscriber Address (if different from patient) Subscriber Home Phone Number Subscriber Day Time Number Secondary Insurance Company Secondary Group # Secondary Subscriber #

PATIENT INFORMATION

Reason for Today's Visit Former Dentist Patient Address Patient City Patient State Patient Zipcode Date of last dental care Date of last dental x-rays Check if you have any of the following: Sores or growths in your mouth Sensitivity when biting Sensitivity to sweets Sensitivity to hot Sensitivity to cold Periodontal treatment Loose teeth or broken fillings Grinding teeth Food collection between teeth Clicking or popping jaw Bleeding Gums Bad Breath How often do you brush? How often do you floss?

MEDICAL HISTORY

Physician' Name Date of Last Visit Have you had any serious illnesses or operations? If yes, describe Have you ever had a blood transfusion? If yes, give approximate dates Are you Pregnant? Nursing? Taking Birth Control? Check if you have had any of the following: Venereal Disease Ulcer Tuberculosis Tonsillitis Tobacco Habit Thyroid Problem Stroke Swelling of Feet Skin Rash Shortness of Breath Scarlet Fever Rheumatic Fever Respiratory Disease Radiation Treatment Psychiatric Care Pacemaker Nervous Problems Mitral Valve Problems Liver Disease Kidney Disease Jaw Pain HIV Positive High Blood Pressure Hepatitis Hemophilia Heart Problems Heart Murmur Headaches Glaucoma Fainting Epilepsy Diabetes Cough Up Blood Persistent Cough Cortisone Treatment Circulatory Chemotherapy Chemical Dependency Cancer Blood Disease Back Problems Asthma Artificial Joints Artificial Heart Valves Rheumatism Arthritis Anemia AIDS Medications Allergies

AUTHORIZATION

"I authorize my insurance company to pay 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 insurance benefits. "

" I understand that I am financially responsible for all charges whether or not paid by insurance. "

I agree to the statement above