New Patients (old) | Callery Dental Care

New Patient Form

Patient Information

First Name

Last Name

Middle Initial

Email

Home Phone

Social Security #

Birthday

Age

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Sex

Male

Female

Patient Emloyed By

Emergency Contact Name

Emergency Contact Home Phone

Whom may we thank for referring you?

Primary Insurance

Person Reasonable For Account

Relation to Patient

Birthday

Social Security #

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Cell Phone

Email

Person Reasonable Employed by

Business Address

Occupation

Business Phone

Business Email

Insurance Company

Insurance Phone

Email

Address

Contract #

Group #

Subscriber #

Name of Other Dependents on This Plan

Pharmacy Name

Pharmacy Phone

Additional Insurance

Is Patient Covered by Additional Insurance? If Not, Ignore This Section.

Yes

No

Additional Insurance Form

Thanks for registering with Callery Dental Care.

Dental History Form

First Name

What would you like us to do today?

Former Dentist

Dentist Email

Date of last dental care

Last Name

Are you in dental discomfort today?

Address

Phone

Date of last x-rays

Please select yes or no if you have had problems with any of the following

Bad Breath

Yes

No

Clicking or popping Jaw

Yes

No

Grinding or clenching teeth

Yes

No

Sensitivity to hot

Yes

No

Sensitivity to sweets

Yes

No

Do you wish your teeth were straighter?

Yes

No

Are you unhappy with any fillings, crowns, or bridges?

Yes

No

How often do you brush?

Bleeding gums

Yes

No

Food collection between teeth

Yes

No

Loose teeth or broken fillings

Yes

No

Sensitivity to cold

Yes

No

Sensitivity when biting

Yes

No

Do you wish your teeth were whiter?

Yes

No

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?

Yes

No

How do you feel about the appearance of your teeth?

Other information about your dental health or previous treatment

Medical History Form Part 1

First Name

Last Name

Physician's Name

Phone

Date of last visit

Are you currently under physician care?

Yes

No

Have you had any serious illnesses or operations? If yes, please describe.

If Yes, Please describe

Have you ever had a blood transfusion?

Yes

No

If Yes, Please give approximate dates

Have you ever taken Fen-Phen/ Redux?

Yes

No

Have you ever used a bisphosphonate medication? Brand names incude:Fosamax, Actonel, Atelvia, Didronal, and Boniva.

Yes

No

Do you smoke or use other tobacco/ smokeless products?

Yes

No

Women: Are you pregnant?

Yes

No

Women: Are you nursing?

Yes

No

Women: Are you taking birth conrol?

Yes

No

Anaphylaxis

Yes

No

Arthritis, Rheumatism

Yes

No

Artificial joints

Yes

No

Atopic ( allergy prone )

Yes

No

Blood disease

Yes

No

Chemical dependency

Yes

No

Circulatory problems

Yes

No

Cough, persistent

Yes

No

Diabetes

Yes

No

Fainting

Yes

No

Glaucoma

Yes

No

Heart murmur

Yes

No

Hemophilian/ Abnormal bleeding

Yes

No

Hepatitis

Yes

No

Jaw pain

Yes

No

AIDS/ HIV Positive?

Yes

No

Anemia

Yes

No

Artificial heart valves

Yes

No

Asthma

Yes

No

Back problems

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Cortisone treatment

Yes

No

Cough up blood

Yes

No

Epilepsy

Yes

No

Food allergies

Yes

No

Headaches

Yes

No

Heart problems, if Yes, Please describe at bottom of form.

Yes

No

Herpes

Yes

No

High blood pressure

Yes

No

Kidney diease or malfunction

Yes

No

Liver disease

Yes

No

Other information about your dental health or previous treatment

Authorization Form

First Name

Middle Initial

Last Name

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.
1 authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered.
I authorize the use of this signature on all insurance submissions.
1 authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Todays Date

I agree to the terms & conditions

Thanks for submitting!

Callery Dental Care, LLC
Sarah E Callery, DDS

New Patients

New Patient Paperwork

New Patient Form

Patient Information

Primary Insurance

Additional Insurance

Dental and Medical History

Dental History Form

Medical History Form Part 1

Medical History Form Part 2

Patient Authorization

Authorization Form

Additional Insurance