New Patient Form

Today's Date: 05/04/2024

What is the reason for your visit?(Required)

Patient's Name(Required)

First Middle Last

Preferred Name

Cell Number(Required)

Home Number

Work Number

Email(Required)

Home Address(Required)

Street Address City State ZIP Code

Birthdate(Required)

Age(Required)

SS Number

Gender(Required)

Male

Female

Other

Marital Status(Required)

Last Dental Cleaning

6 Months

6 Months - 1 Year

1 - 2 Years

Over 2 Years

List Other Family Members Seen By Us

Whom May We Thank For Referring You?

Internet

Postcard

Friend

Medical History

Physician's Name

Physician's Phone

Emergency Contact Name

Emergency Contact Phone Number

Preferred Pharmacy and Location

Pharmacy Phone Number

Date Of Your Last Visit

Please Answer The Following(Required)

	Yes	No
Abnormal Bleeding
Broken Jaw
Diabetes
Drug/Alcohol Abuse
Emphysema
Hepatitis A/B/C
HIV +/Aids
Tuberculosis
Epilepsy/Seizures
Psychiatric Problems
Congenital Heart Defect
Artificial Joints
Artificial Valves
Dental Implants
Orthodontics
Hyper Thyroidism
Hypo Thyroidism
High Blood Pressure
Ulcer/Colitis
Difficulty Breathing
Stroke
Asthma
Sinus Problems
Kidney Disease
Liver Disease
Arthritis
Venereal Disease
Gum Disease
Glaucoma
Fainting
Dry Mouth
Smoke/Tobacco Use
Cancer/Chemotherapy
Heart Surgery/Pace Maker
Surgeries

If you answered yes, please list dates.

For Women Only

Check if you are ALLERGIC to any of the following.

Aspirin

Codeine

Penicillin

Erythromycin

Tetracycline

Latex

Dental Anestetics

Metals

Other

Please list OTHER DRUG ALLERGIES

List MEDICATIONS you are taking

Account Information

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Insurance

Do you have insurance?

Yes

Insurance Information

Insured's Name

Insured's Employer

Employer Address

Street Address City State ZIP Code

Insured's Birthdate

SS Number

Group #

Isured's ID

Insurance Company Name

Insurance Phone Number

Insurance Company Address

Street Address City State ZIP Code

Basic Information About How Our Office Handles Insurance:

As a courtesy to our patients, our office will file all dental insurance claims and give assistance to make sure that your insurance pays to the maximum. We must have all pertinent insurance information.

Our office is not a NETWORK PROVIDER FOR ANY INSURANCE PLAN. Any unpaid insurance balance over 45 days becomes the patient responsibility. All co-payments are due at TIME OF SERVICE. If you have any questions, please see Insurance Billing.

Your initials(Required)

Policies

No Insurance... No Problem!

Ask about our Dental Health Club Plan. Yearly Membership with Savings; No Maximums & No Deductible.

WDW Cancellation Policy

Our desire is to make appointments as comfortable & convenient as possible. If it becomes necessary to cancel an appointment, we requet to be notified 1 business day before time of appointment. this allows us to schedule conveniently for the patient filling the cancellation. Patients breaking or cancelling appointments without this 1 business day notice will be carged $50.00. WDW reserves the right to make exceptions, and forego penalties for short-cancellations with compassionate rationale. These may include but are not limited to: sickness, sudden medical situations, or the death of a close family member.

Your initials(Required)

I understand the information I have given today is correct to the best of my knowledge and it is my responsibility to inform this office of any changes in my medical status.

Signature(Required)

Today's Date: 05/04/2024

This field is for validation purposes and should be left unchanged.

	Yes	No
Are you taking birth control pills?
Are you PREGNANT?
Are you nursing?

127 EAST ELM AVENUE, WAKE FOREST, NC 27587

Medical History

Account Information

Insurance

Insurance Information

Basic Information About How Our Office Handles Insurance:

Policies

No Insurance... No Problem!

WDW Cancellation Policy

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