PLEASE  PRINT  

FAMILY/PATIENT INFORMATION                                                                                                  DATE TODAY _____________

PATIENT NAME _______________________________________COMMON NAME/NICKNAME _________________

MALE [  ]            FEMALE [  ]                                                                 DATE OF BIRTH   __   I__ _ I _____     AGE __________

ADDRESS _________________________________________________ APT ______ CITY, STATE & ZIP ___________________ 

HOME PHONE (      ) ____________ BUSINESS PHONE (     ) _______________ SOCIAL SECURITY #_________________ 

EMPLOYER ____________________________________________ OCCUPATION ____________________________________

EMPLOYER'S ADDRESS ___________________________________ CITY, STATE & ZIP _____________________________

MARITAL STATUS:            [  ] SINGLE                [  ] MARRIED             [  ]  SEPARATED             [  ] DIVORCED [  ] WIDOWED 

SPOUSE'S NAME _____________________________ DATE OF BIRTH    I   _    I____ I____ SOCIAL SECURITY #____________ 

ADDRESS __________________________________________ CITY, STATE & ZIP _________________________________

(If different than above) 

EMPLOYER _____________________________ OCCUPATION _______________WORK PHONE (      )________________

EMPLOYER'S ADDRESS _____________________________ CITY, STATE & ZIP __________________________________

PHYSICIAN _________________________________________ DENTIST __________________________________________

OTHER DENTAL SPECIALIST (i.e., Orthodontist, Periodontist)

REFFERRED TO OUR OFFICE BY ________________________________________________________________________

HAS ANY MEMBER OF YOUR FAMILY BEEN A PATIENT HERE BEFORE? ______________________________________

IF YES, WHOM? _____________________________ RELATIONSHIP TO YOU ____________________________________

NEAREST RELATIVE OR FRIEND NOT AT SAME ADDRESS: __________________________________________________

RELATIONSHIP TO YOU __________________________________  PHONE(               )______________________________

ADDRESS __________________________________ CITY, STATE & ZIP _________________________________________

WHY ARE WE SEEING YOU TODAY? [  ] CONSULTATION [  ] TOOTHACHE EXTRACTION [  ] JAW PROBLEM [  ] INJURY

ARE YOU HAVING PAIN NOW?              YES [  ]                NO [  ]

IF YOU ARE BEING SEEN BECAUSE OF AN INJURY, WHAT DATE DID IT HAPPEN? ____________________________________

WHERE DID IT HAPPEN?____________________________________________EXPLAIN HOW IT HAPPENED______________

______________________________________________________________________________________________________

FULL TIME STUDENTS COMPLETE THIS SECTION:

NAME OF SCHOOL_________________________ SCHOOL CITY_________________________________________________

                                                                                                                                            (data entry by:________________)

F.O.S. #023  (Rev. 5-95)