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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

RESPONSIBLE PARTY

SECONDARY INSURANCE

PATIENT INFORMATION

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

MEDICAL HISTORY

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

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. "