New Patient Information - Dr. Katie Hicks DDS

Step 1 of 6 - Personal Information

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Personal Information

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Date

MM slash DD slash YYYY

Name

First Last

Date of Birth*

Month

Day

Year

Address

Street Address City State / Province / Region ZIP / Postal Code

Best Phone Number*

Employer / School

Who may we thank for referring you?

Emergency Contact Person

Emergency Contact Phone

Name of Responsible Party*

Relationship to Patient

Responsible Party Address

Same as Patient Address

Street Address City State ZIP Code

Employer

Best Phone

Insurance Information

Name of Primary Insured

Their Date of Birth

Month

Day

Year

Relationship to Patient

Social Security #

Insurance Company

Employer

Subscriber ID #

Group #

Insurance Phone #

Upload a copy of your insurance card here

Accepted file types: jpg, pdf, png, Max. file size: 300 MB.

Dental History

Reason for Today's Visit:*

Date of Last Dental Exam/X-Rays/Cleaning?

Month

Day

Year

Former Dentist's Name:

Former Dentist's Address & Phone Number:

Check box if you have had problems with any of the following:

Bad Breath

Bleeding Gums

Clicking or Popping of Jaw

Food Collection Between Teeth

Grinding or Clenching of Teeth

Loose Teeth

Broken Fillings

Periodontal Treatment

Sensitivity to Cold

Sensitivity to Hot

Sensitivity to Sweets

Sensitivity When Biting or Chewing

Sores/Growths in Your Mouth

Other:

How often do you floss?*

How often do you brush?*

Would you like to change the way your teeth look?*

Have you ever had gum (perio) surgery?*

Have you ever had nitrous oxide (laughing gas) while having dental care?*

Have you had bad experiences in dental offices or dental anxiety?*

If yes, is there any way that we can make it easier for you?

Medical History

Primary Physician's Name:

Primary Physician's Phone Number:

Date of last doctor visit:

Have you ever had any serious illnesses or operations?*

Have you ever had a blood transfusion?*

If yes, please describe:

If yes, please describe with dates:

Women: Are you pregnant?

What trimester:

Have you had problems with any of the following:

Anemia

Arthritis, Rheumatism

Artificial Heart Valves

Artificial Joints

Asthma

Back Problems

Cancer

Chemical Dependency

Chemotherapy

Circulatory Problems

Cortisone Treatments

Diabetes

Epilepsy

Fainting/Vertigo

Headaches

Heart Murmur

Heart Problems

Hemophilia

Hepatitis Type B

Hepatitis Type C

High Blood Pressure

HIV/AIDS

Kidney Disease

Liver Disease

Low Blood Pressure

Pacemaker

Radiation Treatment

Respiratory Disease

Rheumatic Fever

Scarlet Fever

Shortness of breath

Sleep Apnea

Snoring

Stroke

Swelling of feet/ankles

Thyroid Problems

Tobacco Habit

Tuberculosis

Ulcer

Other:

Medications

List any medications you are currently taking:

Or upload your medications list here

Accepted file types: jpg, pdf, png, doc, docx, pages, Max. file size: 5 MB.

Pharmacy name & phone number

Allergies

Check boxes if you have allergies to the following:

Latex

Codeine

Local Anesthetic

Sulfa

Penicillin

Other:

Other

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