Newpatient Forms

Welcome to Concourse Dental Group, Dr.
Samira Jaffer and Associates

Personal Information: Mr. Mrs. Ms. Dr. First Name: ____________________ Birthday: month Last Name: __________________ day year
Address: _______________________ Apt #: ____________ City: _______________ Postal Code: _________________ Home Phone: _________________________ Work Phone: ___________________ ext: __________ Cellular Phone: _____________________ Email: _____________________________ Is there anyone we can thank for your referral to our office? __________________________________ Insurance Information - Sending your claims is simple if your insurance information is accurate. If you are insured under your own policy, fill out section A. If you are insured under a family members policy, fill out sec tion B. If you are insured under both, fill out both sections A and B.
Section A I am insured under my own policy.
Section B I am insured under someone elses policy.

Persons name is: ___________________ Their Date of Birth: ____________________ I am related to them because they are my: _______________ The Insuring Company is: _________________ The policy or Group Number is: ______________ My Certificate or ID Number is: ______________ They are employed by: ____________________________
The Insuring Company is: ___________________ The policy or Group Number is: ______________ My Certificate or ID Number is: ______________ Employed By: ____________________________
Emergency Contact Name: ________________________Phone: ____________ Relation: ____________ Your physicians name is: first last Phone Number: Your Medical Specialist is: first last Phone Number: Why do you see this specialist? _____________________________ (i.e. Cardiologist, Oncologist etc)
Dental History
How frequently do you see your dentist? Have you ever been given Oral Hygiene Instruction in: Are any of your teeth sensitive to: Do your gums bleed when: Do your gums feel swollen or tender? Do you catch food in between any of your teeth? Are you aware of any loose teeth? Have you ever had a full mouth set of x-rays? Does your jaw crack or pop when you open it wide? Do you clench or grind your teeth? Clinical Notes: 6 months Yearly Other Last Dental Visit: Brushing Flossing Hot Cold Sweets Other: Brushing Flossing Yes No Yes No Yes No Yes No Date of most recent set: Yes No Yes No Do you wear a night guard?
Medical History
If you have ever experienced any of the following, it is important that we know. Please check off any that apply to you: Do you require premedication (prophylactic antibiotics) before dental appointments? Yes No Do you have Malignant Hyperthermia? Yes No Do you take Daily Aspirin or blood thinners? Yes No Please list Do you use tobacco? Yes No How much per day? Do you regularly use alcohol? Yes No How much per day? Do you regularly use recreational drugs? Yes No How much /type per day? Do you wish to speak with the Doctor about any problem? Yes No
Psychiatric care Hospitalization If yes, why? Radiation treatments Blood transfusions Chemotherapy Prosthetic heart valve Artificial joint or pins Pacemaker Surgery (describe below) Procedure: Date:
Experience problems with healing
Yes No Yes No Yes Yes Yes Yes Yes Yes Yes No No No No No No No
On a prescription diet Tonsillitis AIDS or HIV+ Heart attack Hardening of arteries Anemia Blood disorder Kidney, bladder disease Thyroid Tumors/cancer Other:
Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No
Chest pain (Angina) Dizziness/headaches Shortness of breath Joint pain TMJ syndrome Fainting spells Bleed Excessively Bruising easily Seizures Sinus problems Vomiting, nausea Dry mouth
Heart disease Herpes, cold sores Heart defects/ Heart Murmur Stroke High blood pressure Diabetes Asthma, TB, or lung disease Hepatitis A or B or C Yes Yes Yes Yes Yes Yes Yes Yes
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
No No No No No No No No
Please list your Medications 1. 2. 3.
Please list any Vitamins or Herbs 1. 2. 3.
For Females Only Are you pregnant? Yes No Are you nursing? Yes No Are you taking birth control? Yes No
Please check off any medications you are allergic to or have reacted adversely to:
Ibuprofen (Advil) Aspirin Tylenol Tylenol 2, 3, 4 222, 282, 292 Rovamycin Cedhalexin Chlorhexidene (Peridex)
Nembutal Seconal Naproxen Toradol Codeine Sulpha Drugs Metal Bandage
Demerol Percodan Darvon Penicillin Valium Latex Local Anaesthic (freezing)
Ampicillin Erythromycin Clindamycin Scopolamine Tetracycline Nitrous Oxdide Amoxicillin
Food Allergies please list:
Please list any other medications or substances which you know you are allergic to:
We are happy you have chosen us for your dental care. Is there any dental treatment you would like to know more about?
What do you need from us to make this a positive experience?
The above information is true and correct to the best of my knowledge. I have not omitted any pertinent information. Patient Signature: ___________________________ Date: ________________________________
We want to thank you again for giving us the opportunity to earn your trust. Our goal is to educate you about your dental needs, provide you with treatment options, and help you decide what the best course of action for you is.

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Newpatient Forms

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Welcome to Concourse Dental Group, Dr.

Samira Jaffer and Associates

Section A I am insured under my own policy.

Section B I am insured under someone elses policy.

Yes No Yes No Yes Yes Yes Yes Yes Yes Yes No No No No No No No

Please list your Medications 1. 2. 3.

Please list any Vitamins or Herbs 1. 2. 3.

Nembutal Seconal Naproxen Toradol Codeine Sulpha Drugs Metal Bandage

Demerol Percodan Darvon Penicillin Valium Latex Local Anaesthic (freezing)

Ampicillin Erythromycin Clindamycin Scopolamine Tetracycline Nitrous Oxdide Amoxicillin

Food Allergies please list:

What do you need from us to make this a positive experience?

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