The information provided on this form is important to your dental health. Please complete all of questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.
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Patient Full Name *
Patient's Preferred Name:
Is the patient an insurance policy holder? *
Is the patient the responsible party? *
Please fill out this section, if the responsible party is someone other than the patient. Otherwise, skip to section II.
Responsible Party Information: *
Guarantor First Name:
Guarantor Middle Name:
Guarantor Last Name:
Guarantor Mailing Address:
Guarantor Zip Code:
Guarantor Home Phone:
Guarantor Work Phone:
Guarantor Cell Phone:
Guarantor Date of birth:
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Responsible Party SSN:
Responsible Party Driver's License:
Is the Responsible Party also the insurance policy holder for the patient? *
If yes, please indicate whether primary or secondary insurance holder:
Mailing address: *
Home phone: *
Patient Gender: *
Patient Marital Status:
Driver's License: *
Patient Email: *
Preferred way to contact: *
Dr. Frank Hsu may email confirmations, financial treatment plans, insurance information, and x-rays to myself or other dental providers:
Patient Employment Status:
Does the patient have dental insurance? *
Subscriber's Social Security #:
Subscriber's Birth Date:
Insurance Company Phone #:
Insurance Company Address:
Subcriber's Birth Date:
What was the date of your last dental visit? *
Do you have any tooth related pain (sensitivity)? *
Do you have any jaw related pain (headache, migraine)? *
Do you clench or grind your teeth? *
Do you have frequent bad breath (Halitosis)? *
Do your gums bleed when you floss or brush? *
Do you have any breathing issues that might affect your sleep (ex. Snoring, Sleep Apnea)? If yes, please note which issues:
Did you have orthodontic treatment (braces)? *
Are you happy with your current smile?
Is there anything you would like to change about your smile?
If yes, what would you like to change?
How did you hear about our office?
Who may we thank for referring you to our office?
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