Patient History Name* First Middle Last Prefers to be calledBirthdate* MM slash DD slash YYYY Age*This field is hidden when viewing the formSexSex* Male Female Marital Status* Single Married Divorced Widowed Separated Engaged Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School/Employer*Grade/Position*Email(If over 18) Home PhoneWork PhoneCell Phone*Sibling(s) name(s) and age(s)How did you hear about our office?* Dentist Family Member Other Please SpecifyParent / Guardian (if patient under age 18)Custodial Parent(s) Name(s)Patient Lives With(check all that apply) Mother Father Stepmother Stepfather Grandparents Other This field is hidden when viewing the formDo you have contact information for the patient's father/husband? Yes No Not Applicable Father's Full Name* First Last Title Mr. Dr. Marital StatusHome Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School/EmployerGrade/PositionEmail Address Home PhoneCell PhoneWork PhoneThis field is hidden when viewing the formDo you have contact information for the patient's mother/wife? Yes No Not Applicable Mother's Full Name* First Last Title Mrs. Ms. Miss Marital StatusHome Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School/EmployerGrade/PositionEmail Address Home PhoneCell PhoneWork PhoneThis field is hidden when viewing the formSiblings: Name & AgeThis field is hidden when viewing the formSiblings: Name & AgeThis field is hidden when viewing the formSiblings: Name & AgeThis field is hidden when viewing the formHow did you hear about our office?This field is hidden when viewing the formResponsible Party Email This field is hidden when viewing the formPatient Email (If Over 18) Account Holder / Billing InformationResponsible Party Full Name* First Last Relation to Patient*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Contact Phone #*This field is hidden when viewing the formCell PhoneDo you have dental insurance?*(if yes, please ask for additional insurance form) Yes No Is the patient on SoonerCare?*(only applies if under the age of 18) Yes No Signature of Responsible Party*I certify the above information is true and correct to the best of my knowledge. First Last Signature
