Jameson Dental - Digital Patient Form Are You Filling This Form Out On Behalf of the Patient?YesNoPATIENT INFORMATIONFirst Name(Required) Last Name(Required) Preferred Name Home Address(Required) 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 Phone(Required) Email Gender(Required) Male Female Marital Status(Required) Married Divorced Widowed Single Birthdate(Required) MM slash DD slash YYYY Social Security # Employer Name Occupation Employer 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 Employer Phone Would you like to receive text message reminders?(Required) Yes No Would you like to receive email reminders?(Required) Yes No SPOUSE OR RESPONSIBLE PARTYName (First, Middle Initial, Last)(Required) Relarionship to Patient(Required) Home Address(Required) 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 Phone(Required) Social Security # Employed By(Required) Employer 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 Employer Phone Please list all family members cared for in our office.FirstMiddleLast Add RemoveDENTAL INSURANCEDental Insurance (List in order of Primary, Secondary, etc.)Company NamePhone NumberGroup ID Number Add RemoveMEDICAL HISTORYIn case of an emergency, please notify Emergency Contact Phone # Pharmacy Name Pharmacy Phone # Physician Name Physician Phone # Date of Last Physical Month Day Year List All Medications Presently Taking Add RemoveDo you have allergies or adverse reactions to any medication? Yes No Please list all medications you are allergic to. Add RemoveDO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?(check all that apply) AIDS/HIV Positive Anemia Artificial Heart Valve Artificial Joints Asthma Bleeding Problems Cancer/Chemo/Radiation Cold Sores/Fever Blisters Congenital Heart Issues Diabetes Eating Disorder Emphysema Epilepsy/Seizures Glaucoma Heart Murmur/Mitra! Valve Prolapse Heart Problems/Chest Pains Heart Surgery Hepatitis A B C (circle one) Herpes High Blood Pressure Kidney Problems Neurological/Psychological Problems Pacemaker Rheumatic Fever Seasonal Allergies/Sinus Problems Stomach/Digestive Problems Stroke Thyroid Disease Tuberculosis (TB) Ulcers Currently Pregnant Tobacco Use Alcohol Use I hereby grant permission for dental treatment to be performed and will assume all responsibilities connected with such treatment. A broken appointment is a loss to everyone. Please inform us 48 hours in advance if you are unable to keep your appointment. If you fail to do so, there will be a minimum charge of 50.00.EXAMINATION QUESTIONNAIREDate: 08/12/2024 Name: {First Name:4} {Last Name:77}How long has it been since you've had any of the following?Dental exam Dental x-rays Professional cleaning What prompted you to seek dental care at this time?Are you satisfied with your past dental experiences? Have you had your wisdom teeth removed? Yes No Have you worn braces in the past? Yes No Do you wear an appliance? Yes No How often do you usually perform any of the following?BrushDailyTwice DailyThree or More Times DailyEvery Other DayLess Than Every Other DayFlossDailyTwice DailyThree or More Times DailyEvery Other DayLess Than Every Other DayProfessional CleaningTwice a YearThree Times a YearFour Times a YearYearlyLess than Once a YearDo any of the following pertain to you? Bleeding gums Crooked teeth Discoloration Fatigue Hot/Cold Sensitivity Joint discomfort Poor sleep Chewing sensitivity Clenching/Grinding Congestion Frequent headaches Seasonal allergies Snoring Tender gums Throbbing pain Please explain your selections above.Is there anything you would like to change about the appearance of your smile?Please mark any of the following areas of interest: Whitening lnvisalign Bonding Cosmetic Dentistry Crowns Veneers Snore Guard Night Guard On a scale of 1-10, 10 being very important, how important are your teeth?(Required)Whom may we thank for your referral? I give my permission to use photos of my smile, teeth, and gums in any marketing including, but not limited to website publication, Facebook, print advertisements, newspapers, magazines, electronic media, phonebooks, brochures, fliers and presentations.(Required) I Give My Permission I Do Not Give My Permission