PATIENT INFORMATION

Marital status:
SingleMarriedDivorcedWidowedSeparated

Sex:
MF

CONTACT INFORMATION

Cell Phone Use Policy:
I provide consent to TNT Dental Care to use my cell phone number to calltext (choose one or both) regarding appointments, treatment, insurance, and my account. I understand that I can withdraw my consent at any time.
Check to accept.

Whom may we thank for referring you?
YelpFacebookWebsiteGoogleFriend or Other

When is the best to contact you?
MorningAfternoonEvening

PRIMARY DENTAL INSURANCE INFORMATION

(Please give your insurance card and photo identification card to the receptionist.)

DENTAL INFORMATION

Are you in dental discomfort? YN

Do you wear dentures? YN

Check if you have/had problems with any of the following:
AIDS/HIV positiveAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBruise EasilyCancer/Chemo/RadiationChest Pain Upon ExertionCongenital Heart DisorderDiabetes Type I or IIDrug AddictionHeart Trouble/DiseaseEmphysemaEasily WindedEpilepsy or SeizuresExcessive, Abnormal BleedingFainting Spells/DizzinessFrequent Cough, BronchitisGlaucomaGE Reflux, HeartburnHemophiliaHeart Attack/FailureHeart MurmurHeart PacemakerHepitisis, LiverHigh Blood PressureHives or RashIrregular HeartbeatKidney ProblemsLow Blood PressureMitral Valve ProlapseOsteoporosisPsychiatric CareRheumatic FeverStomach/Intestinal DiseaseSevere or Rapid Weight LossSinus TroubleSleep DisorderStrokeThyroid DisorderTuberculosisTumors or growthsUlcerOther

List any allergies:
Anesthetic (Local)AspirinCodeineLatexMetalPenicillinSulfa DrugsOther

IN CASE OF EMERGENCY

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to TNT Dental Care. I understand that I am financially responsible for any balance. I also authorize TNT Dental Care or insurance company to release any information required to process my claims.

Please sign: