Questionnaire18andOlder - The Dentist for Kids

Patient Name *

First

Last

Patient Date of Birth *

Have you had a cough or fever in the past 2 weeks? *

Have you been exposed to anyone in the past 2 weeks with fever and/or cough? *

Parent’s name and contact number if we need to call: *

First

Last

Any dental problems? *

Please list your dental problems: *

Any specific dental concerns? *

Please describe your dental concerns: *

Any medical changes since last visit? *

Please explain medical changes: *

Any recent hospitalizations? *

Please describe the reasons for your hospitalization: *

Any medications? *

Please list your medications: *

Change of address? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Insurance change? *

Please indicate your insurance, group number, subscriber’s DOB and ID: *

Please upload a copy of the insurance card *

Click or drag a file to this area to upload.

Please upload a copy of your ID: *

Click or drag a file to this area to upload.

Signature *

By signing, I acknowledge that all the information provided on this form is accurate and true to the best of my knowledge.

Patient questionnaire for young adults 18 years and older