Westermeier Martin Dental Care – Cosmetic, Restorative and General Dentistry: New Patient Form

New Patient Form…

Thank you for taking the time to do complete and submit this form to us prior to your first
appointment. This will save time and will help us be better prepared for your first visit with us.

Name

Prefers

Address

City

State

Zip Code

Pronounced

D.O.B.

Home phone

Cell phone

Work

SS#

E-mail

Account information: Person financially responsible:

Employed by

Emergency contact name

Emergency contact no.

Relationship

Name

Relationship

Address

City

State

Zipcode

Dental insurance details:

Primary Policy:

Policy holder

Relationship

D.O.B.

Employer

Carrier

Group#

SS#

ID#

Secondary policy:

Policy holder

Relationship

D.O.B.

Employer

Carrier

Group#

SS#

ID#

Who may we thank for referring you to our office?

Primary concerns

I allow my photograph to be used or displayed for education or promotional purposes

Signed: Date

Date of last health care exam: What was this exam for?

Have you been hospitalized in the last 5 years? No Yes

If yes, reason :

Are you currently receiving care? No Yes If yes, nature of care:

Please list all the names and phone numbers of the physicians who are currently providing your care:

Name Phone

Name Phone

Name Phone

For the following questions check yes or no. The answers are for our records only and are strictly confidential. Please note at during your initial visit our team my ask you additional questions regarding your responses or about your health.

Heart Murmur (Mitral Valve Prolapse) No Yes MS No Yes

Anemia No Yes Fibromyalgia No Yes

Diabetes No Yes Chronic Fatigue No Yes

Epilepsy No Yes Tuberculosis No Yes

Hepatitis, Any Form No Yes Lupus No Yes

Rheumatic Fever No Yes Cancer No Yes

Asthma No Yes Joint Replacement No Yes

HIV Positive or AIDS Related Complex No Yes Glaucoma No Yes

Emphysema or other Respiratory Disease No Yes Abnormal bleeding from a cut No Yes

High Blood Pressure No Yes Liver Disease (including Jaundice) No Yes

Abnormal Heart Condition No Yes Thyroid Disease No Yes

Kidney Disease No Yes Latex sensitivity No Yes

Heart (Surgery, Disease, Attack) No Yes Other No Yes

Venereal Disease No Yes

Latex Sensitivity No Yes

Are you taking any of these medications?

Pre-medication before dental treatment? No Yes Tagamet (Cimetidine)? No Yes

Antacids? No Yes Herbal supplements? No Yes

Have you been treated with Bisphosphonate drugs (Fosamax,Actonel,Boniva)? No Yes

Please list any medications you are currently taking:

1. 2.

3. 4.

5. 6.

Primary Dental Concerns

Women: Are you pregnant? No Yes

If no, are you planning a pregnancy in the near future? No Yes

Are you a nursing mother? No Yes

Are you taking birth control pills? No Yes

High Blood Pressure? No Yes

If yes, what is it usually?

Are you allergic or have you had a reaction to:

a Local Anesthetics No Yes

b Penicillin or other antibiotics No Yes

c Aspirin No Yes

d Codeine, Valium or other sedatives No Yes

e Other

Do you consume grapefruit juice, grapefruit or grapefruit extract?
No Yes

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. I will notify the Doctor of changes in my health and medication.

Patient signature
Date

Who may we thank for referring you to our office?

Primary concerns




I allow my photograph to be used or displayed for education or promotional purposes
Signed:		Date


Date of last health care exam:			What was this exam for?

Have you been hospitalized in the last 5 years?	No Yes


If yes, reason :

Are you currently receiving care?	No Yes			If yes, nature of care:

Please list all the names and phone numbers of the physicians who are currently providing your care:
Name		Phone
Name		Phone
Name		Phone

Heart Murmur (Mitral Valve Prolapse)	No Yes	MS	No Yes

Anemia	No Yes	Fibromyalgia	No Yes

Diabetes	No Yes	Chronic Fatigue	No Yes

Epilepsy	No Yes	Tuberculosis	No Yes

Hepatitis, Any Form	No Yes	Lupus	No Yes

Rheumatic Fever	No Yes	Cancer	No Yes

Asthma	No Yes	Joint Replacement	No Yes

HIV Positive or AIDS Related Complex	No Yes	Glaucoma	No Yes

Emphysema or other Respiratory Disease	No Yes	Abnormal bleeding from a cut	No Yes

High Blood Pressure	No Yes	Liver Disease (including Jaundice)	No Yes

Abnormal Heart Condition	No Yes	Thyroid Disease	No Yes

Kidney Disease	No Yes	Latex sensitivity	No Yes

Heart (Surgery, Disease, Attack)	No Yes	Other	No Yes

Venereal Disease	No Yes
Latex Sensitivity	No Yes

Pre-medication before dental treatment?	No Yes	Tagamet (Cimetidine)?	No Yes

Antacids?	No Yes	Herbal supplements?	No Yes


Have you been treated with Bisphosphonate drugs (Fosamax,Actonel,Boniva)?			No Yes

Please list any medications you are currently taking:

1.		2.
3.		4.
5.		6.


Primary Dental Concerns
Women: Are you pregnant?	No Yes

If no, are you planning a pregnancy in the near future?	No Yes

Are you a nursing mother?	No Yes

Are you taking birth control pills?	No Yes


High Blood Pressure?	No Yes
If yes, what is it usually?


Are you allergic or have you had a reaction to:
a	Local Anesthetics	No Yes

b	Penicillin or other antibiotics	No Yes

c	Aspirin	No Yes

d	Codeine, Valium or other sedatives	No Yes

e	Other






Do you consume grapefruit juice, grapefruit or grapefruit extract?			No Yes


I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. I will notify the Doctor of changes in my health and medication.

Patient signature			Date