Patient Information Form

Use the online form below to submit your information online or click here to download and print the form to bring it in with you. All information submitted electronically is encrypted and secure for your privacy.

General Info
Salutation
Sex
- M
- F
Last Name
First Name
Middle Name
Social Security Number
Birth Date
Address
City
State
ZIP Code
Phone
Email
Employer Information
Employer Name
Occupation
Employer Address
Employer City
Employer State
Employer ZIP Code
Employer Phone
Marital Information
Marital Status
Spouse's Name
Spouse's Occupation
Spouse's Employer
Minor Information
If patient is a minor, who is legally responsible?
Name
Relationship
Birth Date
Address
City
State
ZIP Code
Phone
Employer of responsible party
Social Security Number
Closest Relative
Name
Address
City
State
ZIP Code
Phone
Dental Insurance
Do you have Dental Insurance?
- Yes
- No
Insurance Name
Employer
Family Members Covered
Employer Address
Policy Number
Subscriber Name
ID
Subscriber's Social Security Number
Date of Birth
Dental History
Referral Source
Date of Last Dental Visit
Immediate Dental Concerns
Medical History
Are you sensitive or allergic to any drug or medication?
- Yes
- No
If so, please explain.
Are you under the care of a physician?
- Yes
- No
If so, please explain.
Physician's Name
Physician's City
Are you pregnant?
- Yes
- No
If so, what month?
Are you taking any prescription drugs?
- Yes
- No
If so, please List.
Taking
For
Taking
For
Taking
For
Taking
For
Taking
For
Taking
For
Do you now or have you ever had:
Check the box for all that apply.
- Rheumatic Fever
- Diabetes
- Heart Murmur
- Cancer
- High Blood Pressure
- Hepatitis / Liver Disease
- Heart Pacemaker
- Kidney / Bladder Disease
- Angina
- Frequent Severe Headaches
- Heart Disease
- Bleeding Problems
- Artificial Heart Valve
- HIV
- Mitral Valve Prolapse
- Dizziness / Fainting
- Heart Bypass
- Thyroid Condition
- Psychiatric Problems
- Venereal Disease
- Nervous Disorders
- Arthritis
- Epilepsy / Seizures
- Artificial Joint
- Stomach Ulcers
- Anemia
- Lung Disease
- Radiation Therapy
- Asthma
- Chemotherapy
- Stroke
Do you have any disease or condition that is not listed above that you think we should know about?
- Yes
- No
If so, please explain.
In case of emergency, contact:
Emergency Contact Phone
Consent*
I confirm as true the above health information and realize that withholding any requested information might jeopardize my treatment, health, or safety.
I agree to the Health Information Policy
Payment Policy Consent*
By checking this box, I electronically sign Alamont’s Payment Policy stated below, and I consent and agree to it.
Payment is due when services are rendered unless prior financial arrangement have been made.

A FINANCE CHARGE, computed at a periodic rate of 1.5% monthly (18% annually), will be applied to my balance outstanding sixty (60) days or greater. I am responsible for Alamont’s reasonable collection costs, including court costs and attorney fees. My balance is due within twenty-five (25) days from the billing date shown on my monthly statement unless I have made other arrangements.

I hereby authorize Alamont, any credit bureau, or other investigating agency to investigate or obtain any data pertaining to my credit or financial responsibilities.
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Alamont Dental Associates

401 Martin Luther King Jr.Blvd
Bristol, TN 37620
(423) 968-4422
info@alamontdental.com

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Patient Information Form

General Info

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Closest Relative

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