The following is our patient information form. In order to provide you with better service and to save you some time, this form is provided online. After completion please click the Submit button below, and your information will be securely emailed to our office. You can also download and print this form to complete at your convenience (click here to download), or, of course, you can complete a copy of this form at our office.

At Finley Periodontics your time is important to us. For example, we do not double-book appointments and your appointment time has been set aside for you only. This form is also provided in an effort to maximize your time constraints and as another way to show that we respect your time and appreciate you as our client. We do, however, ask your understanding if a previous patients procedure runs late due to unforeseen circumstances.

Patient Information
Name:
First MI
Last
Gender:

Marital Status:

SSN #:
Birth Date:
Weight:
Height:
Phone:
Home:
Work:
Mobile:
Address:
Street:
City
State Zip
Email Address:
Health Information
Date of Last Dental Visit
Name of Dentist
Reason for the visit
Whom may we thank for referring you to our practice
Have you ever had any of the following? To select more than one item please hold down the Control key and click, to unselect an already selected item perform the same action: hold the control key and click on the item
Please explain if you have any allergies:
Do you have any artificial Joints (please explain):
If you have Diabetes, please specify the type
If you have Hepatitis, please specify the type
For women only:
Are you pregnant?

For women only:
Are you taking birth control?

Have you ever taken any of the following (hold the control key to select more than one item)
Have you ever had any complications following dental treatment

If so please explain
Are you taking any medication at this time

If so please list your medication
Have you been admitted to a hospital or needed emergency care during the past two years?

If yes please explain
Are you under the care of a physician

If yes please explain
Name of the physician
Phone number of the physician
Do you have any health problems that need further clarification

If so please explain
Do you use tobacco

If so what kind and how much
 
Spouse or Responsible Party Information
The following is for:


Person Responsible for payment
Name:
First MI
Last
Gender

Marital Status

Social Security Number:
Date of Birth
Phone:
 Home
Work
Mobile
Address:
 Street
City
State Zip
Dental Insurance Information
PRIMARY
Name of the Insured
Insured's Date of Birth
Phone Number of the Insured
Insured Social Security Number
Relationship to the patient
Insured Adders's:
 Street
City
State Zip
Insured's Employer
Insurance Plan Name
Insurance Plan Address
Insurance Phone Number
Insurance Group Number
SECONDARY
Name of the Insured
Insured's Date of Birth
Phone Number of the Insured
Insured Social Security Number
Relationship to the patient
Insured Address:
 Street
City
State Zip
Insured's Employer
Insurance Plan Name
Insurance Plan Address
Insurance Phone Number
Insurance Group Number