Matix - Medical History Form

MEDICAL HISTORY FORM
Patient Information

All personal information is kept strictly confidential
Name *

Title First Name Middle Name Last Name
Date of Birth

Month Day Year
Date
Social Security Number
Sex
Marital Status
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Fax
Please enter a valid fax number.
Email
example@example.com
Contact preference
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer
Occupation
Emergency Contact/Guardian

First Name Last Name
Phone Number
Please enter a valid phone number.
Primary Physician

First Name Last Name
Phone Number
Please enter a valid phone number.
Pharmacy/Location
Phone Number
Please enter a valid phone number.
General Dentist
Phone Number
Please enter a valid phone number.
Date of Last Dental Cleaning

Month Day Year
Date
Any Pain/Clicking in Jaw? (TMJ)

Yes No
Are you having pain/discomfort?

Yes No
Where?
Have you been treated for periodontal disease in the past?

Yes No
What dental concerns/treatment are you seeking today?
Who may we thank for referring you?
Phone Number
Please enter a valid phone number.
Please read and check the following:

I authorize the release of any information concerning my health care, advice and treatment to another dentist, doctor and/or insurance company for benefits. I understand that a fee may be charged for broken appointments as well as cancellations with less than 24 hours notice. I understand that all professional services are charged directly to the patient and I am responsible for full payment of all fees at time of treatment.
This office does not participate with any insurance carriers. However, we will provide claim forms for you to submit for reimbursement, just present your insurance card at the front desk when you come to our office.

MEDICAL HISTORY FORM

Patient Information

Medical History