New Patient Forms

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Patient Information Last Name First Name Middle Name
Male Female SS# DOB Nickname
Relationship Status: Single Married Minor Separated Divorced Widowed Common-law for years.
Street Address Apt. # City State Zip Code
Home # Cell # E-Mail:
Employer / School Employer / School Phone Employer / School Address Employer / School City Employer / School State Employer / School Zip Code
Spouse / Parent's Name Employer Work #
Who may we thank for referring you to our office?
Person to contact incase of emergency Phone #

Responsible Party Last Name First Name Middle Name
Relation to Patient DOB E-Mail:
Street Address Apt. # City State Zip Code
Home # Cell # Drivers Lic. #:
Bank Employer Work #
Currently a patient in our office? Yes No

Insurance Information Name of Insured Relation to patient
DOB SS# Date employed
Employer Work #
Employer Address City State Zip Code
Insurance Company Group # Union or Local #
Insurance Company Address City State Zip Code
How much is your deductible? $ How much have you used? $ Max Annual Benefit $

Secondary Insurance Information

Name of Insured Relation to patient
DOB SS# Date employed
Employer Work #
Employer Address City State Zip Code
Insurance Company Group # Union or Local #
Insurance Company Address City State Zip Code
How much is your deductible? $ How much have you used? Max Annual Benefit $

Dental History Reason for your visit Date of last dental care
Former dentist Date of last dental X-rays
Street Address City State Zip Code
Have you had any of the following problems? (check all that apply)
Bad breath
Bleeding gums
Clicking or popping jaw
Food collection between teeth
Grinding teeth
Loose teeth or broken fillings
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growths in your mouth

How often do you floss? How often do you brush?

Medical History Physician’s Name Date of last visit

Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Lonimin, Adipex, Fastin (brand names of Phentermine), Pondimin (Fenfluramine) and Redux (Dexfenfluramine). Yes No
Have you ever had any serious illnesses or operations? Yes No
If yes, please explain
Have you ever had a blood transfusion? Yes No If yes, please give approximate date
(Women) Are you pregnant? Yes No Are you nursing ? Yes No Are you taking birth control pills? Yes No
Have you ever had any of the following? (check all that apply)
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints, Pins, etc
Asthma
Back Problems
Bleeding Abnormally
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, Persistent
Cough up Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitus
Hernia Repair
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease

List any medications you are currently taking and the correlating diagnosis:

Allergies:

I certify that I, and/or my dependent(s), have insurance coverage with (Name of Insurance Company(ies)) and assign directly to Dr. all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below. To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

Signature:
Date:
Print Name:
Relationship to patient:

Payment is due in full at time of treatment unless prior arrangements have been approved

Smile Analysis

When I see a picture of myself, the first thing I notice about my smile is?

What do you consider attractive in another persons smile?

Please check any statement you agree with:

I wish the color of my teeth were whiter.
I wish I had a bigger smile.
I think some of my teeth are too large.
I wish my teeth were straighter.
I think my gums show too much when I smile.
I think my smile shows too much space between some of my teeth.
Because I am not totally pleased with my smile, I sometimes hesitate to smile.
I have often wished I could change some of the features of my smile.
I feel as though I don’t really know all of the options available to enhance my smile.
Concerns over what the end result might look like, have been a factor in my not having aesthetic dentistry in my own mouth.
Concerns over fees have prevented me from taking advantage of some of the available options to enhance my smile.
I feel as though I could do a better job protecting the health of my teeth and gums, and therefore, the longevity of my own smile.

Name
EMail
Address
Phone

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Gregory J. Wych, D.D.S.

New Patient Forms

Secondary Insurance Information