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Call: 832-930-7843

HOME
ABOUT US
SERVICES
NEW PATIENTS
BLOG
CONTACT US

Book Appointment

832-930-7843

Patient_info_Online

New Patient Online Form

New Patient Form

Patient Information

Patient Information

First Name*

Last Name*

Birth Date*

SSN*

Gender*

Email Address

Phone Number*

Alt. Phone Number

Address

City

State

Zip

Marital Status

Single

Married

Other

Employment Information

Employment Information

Employment Status

Full Time

Part Time

Self Employed

Student

Retired

Unemployed

Employer

Guardian 1 Name

Responsible Party

Responsible Party / Billing Information

If the patient is the responsible party, please disregard this section

Relationship to Patient

Prefered Name

First Name

Last Name

Birth Date

SSN

Gender

Email Address

Address

City

State

Zip

Phone Number

Employer

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Emergency Contact

Emergency Contact Name*

Relationship to Patient

City

State

Zip

Phone Number*

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Medical History

Are you currently being treated by a physician for a specific condition?*

Yes

No

If so, please tell us about your treatment

Have you recently been hospitalized or had a major operation?*

Yes

No

If so, please tell us about the hospitalization

Are you taking any medications, pills, or drugs?*

Yes

No

Please list all medications and dosage

Are you on a special diet?*

Yes

No

Please tell us about your diet

Do you use tobacco?*

Yes

No

Please tell us how often and what type of tobacco consumption

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Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.

Have you ever been advised that you require antibiotics prior to a dental appointment?*

Yes

No

Please tell us about the antibiotics

Do you take, or have you taken, PhenFen or Redux?*

Yes

No

If so, please tell us about your PhenFen/Redux usage

Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates?*

Yes

No

If so, please tell us about your bisphosphonate usage

Have you recently consumed alcohol?*

Yes

No

Please tell how much alcohol and how recently

Have you recently used controlled substances?*

Yes

No

If so, please tell us which controlled substances and amount/frequency

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Please answer if filling this form out on the day of your appointment

Women (Please check all that apply)

Pregnant

Currently nursing

Trying to get pregnant

Taking oral contraceptives

None of the above

Have you ever had an adverse reaction or allergies to any medication or substance? (Please check all that apply)*

Have you ever had an adverse reaction or allergies to any medication or substance? (Please check all that apply)*

----1Have you ever had an adverse reaction or allergies to any medication or substance? (Please check all that apply)*

Aspirin

Acrylic

Erythromycin

Iodine

------2Have you ever had an adverse reaction or allergies to any medication or substance? (Please check all that apply)*

Latex

Local Anesthetics

Metal

Novocaine

------3Have you ever had an adverse reaction or allergies to any medication or substance? (Please check all that apply)*

Nitrous Oxide

Penicillin

Sulfa Drugs

Tetracycline

------4Have you ever had an adverse reaction or allergies to any medication or substance? (Please check all that apply)*

Valium

Xylocaine

Other

None of the Above

Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *

---1 Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *

Anemia

Leukemia

Stroke

Rheumatism

Liver Disease

Arthritis or Gout

Emphysema

Lung Disease

Convulsions

Hypoglycemia

Tuberculosis

Chest Pains

Excessive Thirst

Tonsillitis

Glaucoma

---2. Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *

Hepatitis (B or C)

Renal Disease

Frequent Diarrhea

Yellow Jaundice

Cancer

Eating Disorder

Heart Trouble

Excessive Bleeding

Jaw Joint Pain

Tumor or Growth

Chemotherapy

Hay Fever

Hive Or Rash

Sinus Problems

Blood Transfusion

---3. Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *

Blood Disease

Shingles

Thyroid Disease

Diabetes

Herpes

Rheumatic Fever

Asthma

Easily Winded

Genital Herpes

Scarlet Fever

Swelling of Limbs

Artificial Joint

Bruise Easily

Heart Murmur

Hepatitis (A)

---4. Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *

Currently Pregnant

Epilepsy or Seizures

Psychiatric Care

X-ray/Chemotherapy

Cold Sores/Fever Blisters

Frequent Cough

Hemophilia

Kidney Problems

Recent Weight Loss

Spina Bifida

Venereal Disease

Low Blood Pressure

Drug/Alcohol Addiction

Mitral Valve Prolapse

Frequent Urination

---5 Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *

Heart Attack/Heart Failure

Irregular Heartbeat

Radiation Treatments

Sickle Cell Disease

Dizziness or Fainting

HIV-AIDS-ARC

Frequent Headaches

High Blood Pressure

Heart Valve or Pacemaker

Congenital Heart Problems

Ulcers or GI Problems

Stomach/Intestinal Disease

Parathyroid Disease

Cortisone Medication

None of the above

Do you have any condition or problem, not listed, which we should know about? Please explain.

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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

Dental History

Dental History

How do you feel about dental treatment?

Relaxed

A little uneasy

Tense

Anxious

Very Anxious

Have you seen a dentist before?

Yes

No

If so, when was your last dental visit?

Are you happy with the appearance of your teeth?

Yes

No

How would you rate your previous dental experience?(1-10) where 1 is poor

What are your dental concerns?

How often do you brush?

How often do you floss?

How often do you use other aids?(water flosser, gum picks, gum stimulator etc..)

Would you like your teeth to be whiter?

Yes

No

Would you like your teeth to be straighter?

Yes

No

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Primary Insured Information

Will you be using insurance?*

Yes

No

Free Text

Skip this section if selected 'No'

Main Subscriber's First Name

Main Subscriber's Last Name

Main Subscriber's Employer

Main Subscriber's SSN

Insurance Company

Main Subscriber's Birth Date

Policy Number

Group Number

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Secondary Insurance Coverage

If you do not have dual insurance coverage, please disregard this section

Main Subscriber's Name

Main Subscriber's Employer

Main Subscriber's Phone Number

Main Subscriber's Birth Date

Main Subscriber's SSN

Main Subscriber's Company

Policy Number

Group Number

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Email and SMS Communication Release

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PATIENT E‐MAIL AND TEXT MESSAGING

Due to the changing world of healthcare and technology, we now have the ability to provide our patients with certain types of information via e‐mail and/or text messaging.

We believe strongly in protecting the privacy of our patients. When you provide this information to us, it is only used as a way to communicate with you. In order to protect your privacy, no confidential or personal information will be sent from us via email or text messaging. We do not share the names, e‐mail addresses, and/or telephone numbers of patients with any other companies, or with any other patient.

Opt-In

I acknowledge that I have read and understand the above statement on emails and text messages. I hereby give permission to send messages to me via the selection(s) indicated below as means of communication. Should I have any questions, I can contact the practice at any time.

Communication Type*

Email and Text

Email Only

Text Only

None

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Authorizations and Acknowledgements

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ACKNOWLEDGEMENT OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Opt-In

Private Practices: I (the patient) have the right to read the Privacy Practices. A copy of the Notice and/or this consent is available upon request and anytime on our website. The Notice provides a description of our practice's treatment, payment activities, healthcare operations and the uses and disclosures we make of your protected health information.

Opt-In

Purpose of Consent: I (the patient) understand and consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

Personal protected information cannot be shared with anyone unless otherwise allowed by HIPAA rules.

First Name*

Last Name*

Email Address

Phone Number

Late cancellation/No show Policy

Late cancellation/No show Policy

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Our goal is to provide quality personal dental care in a timely manner. No shows and late cancellations inconvenience those individuals who need access to dental care. We would like to remind you of our policy regarding missed appointments.

CANCELLATION OF AN APPOINTMENT

CANCELLATION OF AN APPOINTMENT:

To be respectful of the dental needs of other patients, please be courteous and call our office at least 24 hours in advance of your appointment.

NO SHOW POLICY:

NO SHOW POLICY:

A “NO SHOW”, is a patient who missed an appointment without cancelling it. A failure to be present at the time of scheduled appointment will be recorded in the patient’s chart as a “NO SHOW"

A “NO SHOW”, is a patient who missed an appointment without cancelling it. A failure to be present at the time of scheduled appointment will be recorded in the patient’s chart as a “NO SHOW"

How did you hear about us?

How did you hear about us?

Referral Information

Referral Information

Please share with us how you heard about our office. Thank you.

Please share with us how you heard about our office. Thank you.

Please share with us how you heard about our office. Thank you.

Google

Facebook

Website

Yelp

Please share with us how you heard about our office. Thank you.

Family Member

Pediatrician/Physician

Community Event

School/Daycare

Please share with us how you heard about our office. Thank you.

Community Event

Media Ad (radio, movie theater, etc.)

Dentist/Dental Office

Print Ad (magazine, newspaper, etc.)

Please share with us how you heard about our office. Thank you.

Friend

Insurance

Other

Thank you for contacting us.
We will get back to you as soon as possible.

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Contact Information

Phone: 832-930-7843

Fax : 281-692-2254

info@perkdental.com

10237 Bailey Road Suite 107, Manvel, Texas 77578

perk up your smile

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Last Name*:

Email:

Phone*:

How did you hear about us:

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One of our team members will get back to you shortly. If you would like to reach us sooner, please call us at 832-930-7843.

Perk Dental.

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