Patient Form – Dr. Lu Lu

PLEASE PRINT

Date

Patient’s Name

Nickname

Home Address

Home Phone

City

State

Zip

Age

Birth date

Female/Male

If patient is a minor, give parent's or guardian’s name

How did you hear about our office?

Does the patient have or has he/she ever had any of the following conditions?

MEDICAL HISTORY

Heart Murmur

Yes No

Kidney Disease

Yes No

Rheumatic Fever

Yes No

Diabetes

Yes No

Asthma

Yes No

Epilepsy

Yes No

Heart Disease

Yes No

Nervous Disorder

Yes No

Thyroid Disease

Yes No

Tumor, Cancer

Yes No

High Blood Pressure

Yes No

Cardiac Pacemaker

Yes No

Lung Disease

Yes No

Measles

Yes No

Metallic Implant, Shunts, Pins or Rods

Yes No

Tonsillitis

Yes No

Sore Throats

Yes No

Ear aches

Yes No

Tuberculosis

Yes No

Glaucoma

Yes No

Chicken Pox

Yes No

Mumps

Yes No

Prolonged Bleeding When Cut

Yes No

Bad Breath

Yes No

Blood Transfusion

Yes No

Stained Teeth

Yes No

Injury to Front Teeth

Yes No

Cold Sore, Fever Blister

Yes No

Bleeding Gums

Yes No

Women: Are you Pregnant Now?

Yes No

ADD /ADHD  Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder

Yes No

AIDS

Yes No

Hepatitis/Liver Disease

Yes No

Chemical Dependency

Yes No

COMMENTS

Drug/ Food Allergy

Yes No

Developmentally Delayed

Yes No

If yes, to what medications/foods?

Age level patient is at

Is the patient taking any medications?

Yes No

Has the patient recently been under the care of a physician?

Yes No

If so, please list the medications

Reason

Name of Medical Doctor for above reason

Has the patient been hospitalized in the last 5 years?

Yes No

Has the patient had a serious illness or operation?

Yes No

If yes, please explain

Has the patient had difficulties in a dental office?

Yes No

If yes, please explain

Is there any other health information that should be known?

Last dental care

Date

Name

Address

Has any member of your family received dental treatment in this office before?

Yes No

If yes, please fill in the name

Names of other children in family

Name of family dentist

PEDIATRIC DENTISTRY SECTION

(To be filled out by parent or guardian)

Last well checkup

Name of pediatrician or primary care physician

Phone

Are test and Immunizations (DPT, diphtheria, tetanus, whooping cough, measles and polio, vaccines) up to date?

Yes No

Has he/she had a skin test for tuberculosis?

Yes No

Is he/she doing well in school?

Yes No

Does he/she get along well with other children?

Yes No

Does your child have any limitations to physical activities?

Has your child had any history of being under oxygen or general anesthesia?

Does the child have a specific problem that needs attention?

Yes No

Child’s pets and hobbies

Choose if applicable

Toothache Orthodontics Home Care Instructions

ORTHODONTIC SECTION

Is he/she a mouth breather?

Yes No

Have you ever been informed of any missing or extra permanent teeth?

Yes No

If so when

While asleep While awake

Has he/she had any injuries to the face, mouth, or teeth?

Yes No

Has he/she ever experienced any popping, clicking, pain or limitation of movement in the temporomandibular joint (TMJ)

Yes No

If yes, please explain

Does he/she experience headaches on a regular basis?

Yes No

Has an orthodontist been consulted previously?

Yes No

EMERGENCY INFORMATION

Name of nearest relative not living with you

Complete Address

Phone

RESPONSIBLE PARTY INFORMATION

Resident Parent

Last

First

Middle Initial

Middle Status

Address

Street

City

State

ZIp

How long at this address

Home Phone

E-mail Address

Cell Phone

Previous Address (if less than 3 yrs.)

Street

City

State

Zip

Social Security #

Birth date

Relationship to patient

Employer

Occupation

Yrs. Employed

Employer’s Address

Work Phone

Other Parent

Last

First

Middle Initial

Middle Status

Address (if not the same)

Street

City

State

Zip

Social Security #

Birth date

Relationship to patient

Home Phone

Work Phone

Employer

Occupation

Yrs. Employed

Employer’s Address

Cell Phone

DENTAL INSURANCE INFORMATION

Primary Insured’s Name

Insured’s Soc. Sec. #

Insurance Company

Group No.

Local No.

Insurance Co. Address

Insurance Phone #

Do you have dual coverage?

Yes No

Secondary Insured’s Name

Insured’s Soc. Sec. #

Insurance Company

Group No.

Local No.

Insurance Co. Address

Insurance Phone #

I give my consent for the Doctors of this office to do a complete/emergency oral and dental examination on the patient named previously. X-rays that are necessary to properly complete the exam may be taken. If a cleaning, fluoride treatment and oral hygiene instructions are to be included in the first examination, I will be informed.

Any additional treatment received will be fully explained prior to starting treatment at each visit.

I agree to inform the doctors of any changes in medical or financial information.

I understand a credit report might be obtained.

Initials:

Requirement for Filing Insurance Claims: I authorize the release of any information relating to any dental claims and understand that I am personally responsible for all costs of dental treatment. I hereby authorize payment directly to to the dentist that performs services for treatment on my child.

By initializing this statement I accept financial responsibility for this child

Additional comments:

Date

Print (Parent or Guardian)

Signed (Parent or Guardian)

PATIENT’S REGISTRATION AND HISTORY

PLEASE PRINT

MEDICAL HISTORY

Last dental care

PEDIATRIC DENTISTRY SECTION

ORTHODONTIC SECTION

EMERGENCY INFORMATION

RESPONSIBLE PARTY INFORMATION

Resident Parent

Address

Previous Address (if less than 3 yrs.)

Other Parent

Address (if not the same)

DENTAL INSURANCE INFORMATION

We can't wait to meet you!

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PATIENT’S REGISTRATION AND HISTORY

PLEASE PRINT

MEDICAL HISTORY

Last dental care

PEDIATRIC DENTISTRY SECTION

ORTHODONTIC SECTION

EMERGENCY INFORMATION

RESPONSIBLE PARTY INFORMATION

Resident Parent

Address

Previous Address (if less than 3 yrs.)

Other Parent

Address (if not the same)

DENTAL INSURANCE INFORMATION

We can't wait to meet you!

Navigation

Contact Us

Office Hours

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