West Valley Dental

West Valley Dental Patient Information Form

Please complete the fields below. Upon a successful submission, West Valley Dental will capture your information. Thank you.

PATIENT INFORMATION

First Name*

Middle Name

Last Name*

Address*

City*

ZIP*

Social Security Number*

Home Phone*

Mobile Phone*

EMail Address*

Birthdate*

Occupation*

Employer

Employer Address

Work Phone
SPOUSE

First Name

Middle Name

Last Name

Home Phone

Occupation

Employer

Employer Address

Work Phone

RESPONSIBLE PARTY FOR THE ACCOUNT

Name*

Employer Address
Dad's Name

Dad's Employer

Dad's Employer Address

Work Phone

Home Phone
Mom's Name

Mom's Employer Name

Mom's Employer Address

Work Phone

Home Phone

DENTAL INSURANCE

Do you have dental insurance or Title XIX?*

Please bring insurance forms for each dental visit.

Primary Insurance Company

Primary Insurance Subscriber's Name (Person who carries the insurance)

Social Security Number

Primary Insurance Subscriber's Birthdate
Secondary Insurance Company

Secondary Insurance Subscriber's Name (Person who carries the insurance)

Social Security Number

Secondary Insurance Subscriber's Birthdate

EMERGENCY CONTACT

Other than the names listed above, whom should we contact in case of an emergency?

Emergency Contact Name*

Emergency Home Phone*

DENTAL HISTORY

Who referred you to West Valley Dental?*

Purpose of this visit?*

Describe any nervousness with dental treatments*

Date of last dental treatment*

Date of last x-rays*

Former Dentist (Name and City)*

Have you ever had any of the following?

Bad dental experience?*
Accident to the jaw, mouth or tooth?*
Recurring painful, unheaded area in the mouth?*
Gum abscess (boil) or painful mouth infection?*
Treatment for gum disease?*
Receive instructions for proper home care?*
Do your gums bleed when you brush?*
Are your teeth senstive to hot, cold or sweets?*
Are your teeth senstive to chewing or pressure?*
Do you clench or grind your teeth?*
Do your jaw ever feel tired or sore?*
Have you ever had pain in/near your ear?*

MEDICAL HISTORY

Women: Are you pregnant now or anticipaing becoming pregnant?

To the best of my knowledge all of the preceding answers are true and correct. If I ever have any change in my health or medications, I will inform the dentist at the next appointment without fail.

I herewith give my consent to the performing of dental procedues agreed to be necessary or advisable, including x-rays and local anesthesia.

Your Electronic Signature (type your name below)*

To prevent automated sign ups, what is the sum of zero and two* (enter the number not the text name)