We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health. Step 1 of 4 25% Patient InformationName* First Last Date of Appointment* Primary Phone Number*Secondary Phone NumberSS/HIC/Patient ID #Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Sex*MaleFemaleAge*Please enter a value between 0 and 100.Date of Birth* MM DD YYYY StatusMarriedSeparatedWidowedDivorcedSinglePartneredMinorAdditional InformationPatient Employer/SchoolWhom may we thank for referring you?Emergency Contact Name First Last Emergency Contact Phone Primary InsurancePerson Responsible for Account First Last Relation to PatientDate of Birth (Insurance Holder) MM DD YYYY Social Security NumberAddress (If different from patient's) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmployment StatusEmployed Full-TimeEmployed Part-TimeSelf-employedNot employedbut looking for workNot employed and not looking for workHomemakerRetiredStudentPrefer Not to AnswerEmployer/OccupationInsurance CompanyContract NumberGroup NumberSubscriber NumberNames of other dependents covered under this plan Dental HistoryReason for VisitDate of Last Dental Care Date of Last Dental X-Ray Former Dentist Name Check if you have had problems with any of the following: Bad breath Grinding teeth Bleeding gums Clicking or popping jaw Food collection between teeth Sensitivity to hot Loose teeth or broken fillings Periodontal treatment Sensitivity to cold Sensitivity to sweets Sensitivity when biting Sores or growths in your mouth How often do you floss?More than once a dayOnce a dayOnce a week2 to 3 times a weekOnce a month2 to 3 times a monthLess than once a monthHow often do you brush?More than once a dayOnce a dayLess than once a dayMedical HistoryPhysician's Name Date of Last Visit Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).YesNoHave you had any serious illnesses or operations?YesNoIf yes, describe:Have you had a blood transfusion?YesNoIf yes, give approximate date: (Women) Are you pregnant?YesNo(Women) Are you nursing?YesNo(Women) Are you taking birth control pills?YesNoSelect if you have or have had any of the following:AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCough up BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal DiseaseList medications you are currently taking:List your allergies (if any): AuthorizationI certify that I, and/or my dependent(s), have insurance coverage with the insurance company stated above and assign directly to Dr. Markowitz all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.Name of Patient, Parent, Guardian or Personal Representative (Digital Signature)* This serves as your digital signature and agreement to the above statement.Relationship to PatientType "Self" if you are the patient.CommentsThis field is for validation purposes and should be left unchanged.