Patient History Form

Name *

First

Last

Date of Birth *

dd/mm/yyyy

Address *

Cell Phone Number *

Email *

Preferred Method of Contact

Text
Email
Phonecall

Emergency Contact

Name and Phone Number

Primary Insurance Information

Name of Insurance Company and Policy Number

Primary Insurance Policy Holder

Policy Holder Name , Date of Birth (dd/mm/yyyy), and Certificate ID Number

Secondary Insurance Information (if applicable)

Name of Insurance Company and Policy Number

Secondary Insurance Policy Holder

Policy Holder Name, Date of Birth (dd/mm/yyyy), and Certificate ID Number

Medical History (To Ensure a Safe Visit, Please Complete the Following) *

Family Physician’s Name and City

Please check any conditions below that apply *

Acid Reflux
Allergies
Anxiety
Arthritis
Bleeding Disorder
Breathing Problems
Cancer
Chemotherapy
Dementia
Diabetes
Fainting
Heart Condition
Hepatitis
High Blood Pressure
Human Papilloma Virus
Immunocompromised
Joint Replacement
Nutritional Disorder
Osteoporosis
Pacemaker
Pregnancy
Radiation Therapy
Seizures
Stroke
Other (please describe below)
None of the above apply to me

Please add any further comments here

Please list any current medications or supplements *

Dental History

Name and Location of Current Dentist, Approximately how long since last visit

How often do you usually have your teeth professionally cleaned?

3-4mths
4-6mths
6-9mths
9-12mths
once in awhile

Please check all that apply

Latex allergy
Sensitive teeth
Bleeding/painful gums
Clenching/grinding
Jaw locks/pains
Wearing a nightguard
Play sports
Bad taste/odor
Nervous of dental care
Unusual reaction to dental products
Not happy with the look/feel of my teeth (please describe below)

Please add any further comments here

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By printing my name below and submitting this form via return email, I acknowledge the submission of my personal information and health history to Word of Mouth Dental Hygiene. *

Name and Date (dd/mm/yyyy)

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