New Patient History Form - APEX Dental

Step 1: Patient Information
Patient Name*
Please type your full name.

Date of Birth*
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Cell Phone*
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Home Phone
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WorkPhone
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E-mail*
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Marital Status*
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Gender*
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Patient Employer
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Employer Phone
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Emergency Contact*
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Emergency Phone*
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Are you currently under care of a physician?*
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If yes, explain
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Physician Name
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Physician Phone
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Do you have any of the following?

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Taking any medications?
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Are you allergic to:
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If Other
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Are you pregnant?
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Due Date
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Step 3: Dental History
Reason for Visit?*
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Any Pain?*
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Date of last dental visit?
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Date of last radiographs?
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Date of last cleaning?
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Have you been told that you require antibiotics before dentals visits?*
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If yes, please explain
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Do you experience sensitive teeth?
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Sore or bleeding gums?
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Loose Teeth?
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Jaw pain or noise?
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Step 4: Dental Insurance Information
Insured Person's Name*
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Relation to Patient
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Street Address*
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City*
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State*
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Zip Code*
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Date of Birth*
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Employer's Name
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Insurance Company
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Employer's Phone
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ID #
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Group #
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By submitting you are consenting that you have read/agree to the HIPAA Notice of Privacy Practices.
Type Numbers*
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7690 Highway 72 West, #101 · Madison, Alabama 35758 · (256) 864-2739
APEX Dental is rated 4.8 out of 5 based on 35 Google+ reviews.