New Patient Forms – Timothy Pohlman, D.D.S.

Name*

First Last

Email*

Home Phone*

Cell Phone

Birthdate*

Address*

Street Address Address Line 2 City State ZIP Code

Medical History

Have you ever had any of the following diseases or medical problems?

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline

Please list any other drugs/materials that you are allergic to:

Your current physical health is:

Good
Fair
Poor

Are you taking any prescription / over-the-counter or herbal supplement drugs?

Yes
No

Please list each one:

Have you ever taken Fosamax, or any other bisphosphonate?

Yes
No

Have you ever taken Phen-fen?

Yes
No

For Women: Are you using a prescribed method of birth control?

Yes
No

Are you pregnant?

Yes
No

Week #:

Are you nursing?

Yes
No

Do you require antibiotics before dental treatment?

Yes
No

Are you currently in pain?

Yes
No

Do your gums ever bleed?

Yes
No

Have you ever had a serious / difficult problem associated with any previous dental work?

Yes
No

Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?

Yes
No

Your current dental health is:

Good
Fair
Poor

Do you like your smile?

Yes
No

Would you like whiter teeth?

Yes
No

Would you like fresher breath?

Yes
No

How many times a week do you floss?

How many times a day do you brush?

Which type of bristles?

Soft
Medium
Hard

Do you smoke or use tobacco in any form?

Yes
No

Insurance Coverage

Dental Coverage

Yes
No

Insurance Company Name

Insurance Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Company Phone

Group # (Plan, Local, or Policy #):

Insured's Name

First Last

Relation

Insured's Birthdate

Insured's ID #:

Insured's Employer:

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

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

Signature*

Today's Date*