Test Form

Home Test Form

About You:

Your Name
MM slash DD slash YYYY
Marital Status
MM slash DD slash YYYY
Home Address
Work Address

Emergency Contact

Emergency Contact Name

Spouse/Partner/Significant Other Information:

His or Her Name

Person Financially Responsible:

MM slash DD slash YYYY

Insurance and Financial Information

Insurance Coverage
Subscriber's Name
Patienship Relationship to Subscriber
MM slash DD slash YYYY
Secondary Coverage
Subscriber's Name
Patienship Relationship to Subscriber
MM slash DD slash YYYY
I give my consent to bill my insurance and to providing any necessary documents and or records needed(Required)

Medical History:

Your current physical health is
Are you currently under the care of a physician?
MM slash DD slash YYYY
Are you taking any prescription medications?
Do you smoke or use chewing tobacco?

For Women:

Are you pregnant?
Are you nursing?
Are you taking birth control pills?

Medical Problems:

Have you had any serious medical problems within the past 5 years?

Have you ever had, or been treated for any of the following diseases or medical problems?

Heart Attack/Stroke
Psychiatric problems
Artificial Bones/Joints/Valves
Blood Transfusion
Heart Murmur
Rheumatic Fever
High/Low Blood Pressure
Abnormal Bleeding
Kidney Problems
Drug/Alcohol Abuse
Asthma/Breathing Problems
Herpes/Fever Blister
Migraine Headaches
Heart Defects
Thyroid Problems
Liver Disease
Venereal Disease
Sickle Cell Disease
Sinus Problem

Sleep Apnea

Have you been diagnosed with Obstructive Sleep Apnea?
Do you snore?
Do you have fatigue?
Do you have an interest in Oral Appliances?

Are you allergic to any of the following?

Dental Anesthetics

Our Office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.


Do you need to be pre-medicated before dental treatment (history of heart murmur, bacterial endocarditis, mitral valve prolapse, etc., presence of metal plates, pins and rods in the body)?
MM slash DD slash YYYY
Previous dentist's name
Are you currently in pain or discomfort?
Have you ever had any serious problems with previous dental work?
Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?
Do you have problems with bad breath?
Do your gums ever bleed when you brush or floss?
If you could easily and safely whiten your teeth, would you be interested?
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
Do you grind or clench your teeth?

Choose one from each dropdown list:

Insurance companies now allow for “functionally acceptable work,” whereas, in the past their coverage was for “quality work.” It is our desire to provide our patients with the highest quality work within their financial capabilities and desires. What is important to you? (Please check one)
The following best describes my reason for seeking dental care (please check only one).
Has anything kept you from receiving dental treatment in the past?

Patient Goals and Expectations:

Check one that represents the level of dental care you believe currently exists in your mouth, today.
Check one to represent where you would like to see your level of dental health.
Check one to represent where you believe your insurance reimbursement pays.
I understand that the information that I have given today is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. I assume the financial responsibility and obligation associated with the treatment I consented to.
Reset signature Signature locked. Reset to sign again
MM slash DD slash YYYY
Your overall health can significantly affect your oral health and a thorough health record allows us to make a more complete diagnosis. Thank you for taking the time to fill out these forms.