Carl A. Jacobson, DDS

Bret H. Jacobson, DDS

Home Staff Dentists Hygienists New Patients Services Contact

 

New Patient Exam

During your first visit, we will do a complete exam including confidentially reviewing your medical history, charting your existing oral health condition, carefully checking for any new changes in you dental status, a cancer screening, joint and jaw exam, checking how your teeth function and periodontal (gum) health screening.

During the first visit, most importantly, we listen.  After your needs, concerns and goals have been discussed, we are able to schedule appointments for any necessary treatment, including a cleaning.

This way, patients are in control of the decisions that fulfill their dental health needs. They are able to express any anxiety regarding dental treatment so we can ensure gentle and painless dental care.  We also have a staff very familiar with dental insurance who will be able to inform you of financial considerations concerning any treatment.

All new patients need to complete a new patient form.  To save time, you may fill out the form below so we can review all the information and be ready for your first appointment. 

Please print the form, fill it out and either fax it or bring it with you.  Once you have completed the form, please call or email our office to schedule an appointment. 

 


New Patient Form

Please read carefully.  If you have questions, please call us during business hours or email us anytime.

Telephone: 253-839-4111   Fax: 253-839-3573   Email:information@jacobsondds.com

General Information
   
Purpose of Visit:
Soc. Sec #: Date
First Name:   Last Name:       Middle Initial:
Home Address:   Address cont:
City:   State/Province:   Zip/Postal Code:
Birthdate:   Home Phone: Marital Status:
 
Patient's or Parent's Employer:   Work Phone:
Work Address:   Address cont:
City:   State/Province:   Zip/Postal Code:  
 
Spouse or Parent's Name: Employer:
Work Phone:
 
If patient is a student, fill in below:
Name of School/College: City: State:
 
Whom May We Thank for Referring You? 
 
Responsible Party
 
Responsible Party:   Relationship:
Birthdate:   Home Phone: Work Phone:
Address:
Is this person currently a patient in our office?
 
Insurance Information
 
Name of Insured:   Relationship:
Birthdate:   Soc. Sec #: Date employed:  :
Name of Employer:   Work Phone:
Employer Address:
City: State:   Zip/Postal Code:  
Insurance Company: Group Number:
Insurance Co. Address:   City:
State:   Zip/Postal Code:  
Union or Local Number:  
 
DO YOU HAVE ADDITIONAL INSURANCE?
 
Name of Insured:   Relationship:
Birthdate:   Soc. Sec #: Date employed:  :
Name of Employer:   Work Phone:
Employer Address:
City: State:   Zip/Postal Code:  
Insurance Company: Group Number:
Insurance Co. Address:   City:
State:   Zip/Postal Code:  
Union or Local Number:  
 
MEDICAL HISTORY
Name of physician:    City:    Phone:
Do you have a current medical problem?
Please describe:
Have you ever had any of the following:
Nervous breakdown, psychotherapy Shortness of breath
Lung trouble (TB, asthma, emphysema) Swelling of ankles or feet
Hepatitis, liver disease, jaundice Pain, pressure or tightness in chest
Positive test for HIV Heart attack
Arthritis, sore joints Rheumatic fever
Diabetes High blood pressure
Excessive bleeding Fainting spells, convulsions, epilepsy
Blood trouble, anemia, leukemia Headaches when lying down
VD (syphilis, gonorrhea) AIDS
X-ray, indium, cobalt treatments  
   
Are you now:
Pregnant Using anticoagulants
On a prescribed diet Using Dilantin
Using Thyroids Taking medicines, please specify:
Using hormones (including birth control
 
Are you now taking or using medicines for:
Diabetes (pills or shots) Blood (liver, iron pills)
Nerves (tranquilizers) Headaches
Sleeping Arthritis or rheumatism
Heart or blood pressure (digitalis, nitroglycerin, resorpin) Allergy
   
Have you ever been sick from, shown an allergy to, or told not to take:
Antibiotics Novocaine (or other dental anesthetic)
Codeine Other drugs or medicines, please specify
 
 
   
Have you ever had a tumor or cancer?   Where?
Have you ever had a major operation? What kind:
Have you ever been involved in a major accident?   :
Please describe:  
   
Following injuries, have you ever had bleeding problems?
Do injuries and cuts take longer to head now than previously?
Have you had eye trouble recently?
Do you urinate more than 6 times a day?
Have you recently lost weight unintentionally?
Is there a history of diabetes in your family?
Date of last medical exam?
Have you come to this office for relief of pain?    If yes, where is the pain?
Have you had the pain more than 3 weeks?
Are you presently having dental pain?
 
DENTAL HISTORY
   
How long has it been since your last dental visit?
Have you had orthodontic treatment?
Do you have un-replaced missing teeth?
If yes, why haven't you had them replaced?
         was it ever suggested
Do you have difficulty swallowing?
Do your gums bleed when brushing your teeth?
Have you ever been told you have pyorrhea?
Have you ever had professional instructions on dental home care?
Is any part of your mouth sensitive to temperature, or pressure?
       if yes, which part?
Does food catch between your teeth?
       if yes, where?
Do you have any pain or soreness around the eyes, or ears?
Do you have any unpleasant odor, or taste, in your mouth?
Are you dissatisfied with your teeth and their appearance?
Do you always have something to be treated or repaired when you visit a dentist?
Do you feel that in the past you have required a lot of dental work?
       if yes, has it been to replace previous dentistry?, and/or to repair a new decay? 
Are you aware that dental decay is essentially a childhood disease, and that most tooth filling procedures are to replace broken fillings or temporary dentistry?
Do you feel that you will lose more teeth and eventually have to wear full dentures?
       if so, at what age:  
Are you deeply concerned about the finances required to return your mouth to dental health?

 

 

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Copyright © 2002 Dr. Bret Jacobson, Dr. Carl Jacobson
Last modified: May 19, 2003