Welcome and thank you for choosing Somerset Dental. In order to serve you promptly, we will need the following information. All information will be strictly confidential.

Dear New Patient,

Please allow me to welcome you into our family of patients. My team and I are honored that you have chosen us to care for your dental needs and we look forward to becoming your “partner in health”. Our practice is prevention-oriented, so you can expect your initial examination in our office to include all necessary x-rays and cancer screenings. We have learned over time that detecting problems at an early stage saves our patients valuable time and money.

We realize that you are an individual with unique preferences, therefore we will strive to tailor our approach to your needs. If you have special needs or concerns, please advise us—your input is appreciated and essential for us to serve you properly. We will also provide you with a variety of financing options from which you may choose.

We are proud of our highly trained team, each of which is carefully chosen for his or her ability to serve you in a gentle way. We appreciate the value of your time and except for emergencies in our day, you can expect us to be on time for you. We hope to receive the same courtesy from you. Please complete the health and patient questionnaire below and click “send” at least one day before your first visit. Should you have any questions, please do not hesitate to call. All of us are looking forward to meeting you at your first visit.

Sincerely,
Sufia Palluck, DDS

#1 About You

First Name Last Name MI

I like to be called

 

Birth Date Marital Status S M D

Home Phone # Work # Cellular #

When is the best time to contact you?

Email Address

Please tell us an interesting fact about yourself

 



Home Address Apt#

City State Zip Code

 

Your Employer Employer Address

Employer City Employer State Employer Zip Code

Occupation

 


If Student, School: School City School State

 

Nearest friend or relative not living with you? Name: Phone #:

Relationship: Address

City State Zip Code

 

Who may we thank for referring you?

 



#2 Dental Insurance

Do You Have Dental Insurance? Yes No

If yes, please provide the following information:

This insurance is through: Self Spouse Parent Other

Name of Insurance Subscriber:

Insurance Subscriber's Employer:

Insurance Subscriber's SSN: Birthdate:

Dental Insurance Company # 1: Group #:

Insurance Phone #:

 



Do you have any other dental insurance coverage? Yes No

If yes, please provide the following information:

This insurance is through: Self Spouse Parent Other

Name of Insurance Subscriber:

Insurance Subscriber's Employer:

Insurance Subscriber's SSN: Birthdate:

Dental Insurance Company # 2: Group #:

Insurance Phone #:

I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage.

 



#3 Dental History

What is the reason for your visit today?

Date of last dental visit: Last dental cleaning: Last full mouth x-rays:

Previous dentist's name:

Address: Phone:

 

How often do you have examinations? How often do you brush your teeth?

How often do you floss? What other dental aids do you use? (interplax, toothpick, etc.)

 

Do you have any dental problems now? Yes No

If yes, please describe:

 

Is there anything about having dental treatment that you would like us to know? Yes No

If yes, please describe:

 

 

Have you ever had:

A) Orthodontic Treatment? Yes No

 

B) Periodontal Treatment? Yes No

 

C) Oral Surgery? Yes No

 

Do your gums bleed or hurt? Yes No

 

Have you ever experienced clicking or popping of the jaw? Yes No

 

Do you experience any pain to your jaw, ear, or side of your face? Yes No

 

Do you feel nervous about having dental treatment? Yes No

If yes, what is your biggest concern:

 

Have you had an upsetting dental experience? Yes No

If yes, please describe:

 

 

Have you been under the care of a medical doctor during the past two years? Yes No

If yes, for what:

Physician name: Address:

Phone:

 

Have you taken medications or drugs during the past two years? Yes No

If yes, for what:

 

Are you taking any medications, drugs or pills now? Yes No

If yes, please list name & dosage:

 

Are you aware of having an allergic (or adverse reaction) to any medication or substance? Yes No

If yes, please list:

 

 

Indicate which of the following you have had or have at present. (Check One for Each)

Heart (surgery, disease, attack)

Yes No

Chest pain

Yes No

Heart Murmur

Yes No

High Blood Pressure

Yes No

Artificial Heart Valve

Yes No

Mitral Valve Prolapse

Yes No

Heart Pacemaker

Yes No

Rheumatic Fever

Yes No

Arthritis/Rheumatism

Yes No

Stroke

Yes No

Diet (special/restricted)

Yes No

Artificial Joints

Yes No

Kidney Trouble

Yes No

Ulcers

Yes No

Diabetes

Yes No

Contact Lenses

Yes No

Emphysema

Yes No

Tuberculosis

Yes No

Chronic Cough

Yes No

Asthma

Yes No

Latex Sensitivity

Yes No

Allergies/Hives

Yes No

Sinus Trouble

Yes No

Radiation Therapy

Yes No

Chemotherapy

Yes No

Tumors

Yes No

Psychiatric Care

Yes No

Fainting/Dizzy Spells

Yes No

Hepatitis

Yes No

Venereal Disease

Yes No

A.I.D.S.

Yes No

H.I.V. Positive

Yes No

Cold Sores

Yes No

Fever Blisters

Yes No

Blood Transfusions

Yes No

Hemophilia

Yes No

Sickle Cell Disease

Yes No

Liver Disease

Yes No

Yellow Jaundice

Yes No

Neurological Disorder

Yes No

Epilepsy/Seizures

Yes No

 

Do you have or have you had any disease, condition, or problem not listed? Yes No

If yes, please list:

 

Women: Are you pregnant? Yes No

If yes, Months:

Nursing? Yes No

Taking birth control pills? Yes No

 

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.