Patient Information

Please provide the following information to help make your first appointment go smoothly. Please provide as much information as possible and while not every question requires a response, the more information you provide the higher the quality of service we're able to provide.

Patient's Full Name * 🛈

Please enter any updates to your address or contact information:

Address:

City:

State:

Zipcode:

Phone #:

Email:

Appointment Location? *

Gender: *

Male

Female

Patient Medical History

Have you been seriously ill since your last office visit? *

Yes

No

Have there been any changes in your general health since you last office visit? *

Yes

No

If yes, please explain: *

Is A Medical Doctor Currently Treating You? *

Yes

No

If yes, please explain: *

Physician's Name: *

Physician's Contact #: *

Please list any medication (Prescription or Over-the-Counter) that you take.

Are you allergic to, or have you had unusual reactions to any of the following? (If none select 'No Known Allergies')

Penicillin

Aspirin

Iodine

Sulfa Drugs

Barbiturates

Codeine

Latex

Erythromycine

No Known Allergies

Other

If 'Other', Please Explain *

Have you ever had or been told you have any of the following?

Heart Defect................... *

Yes

No

Infective Endocarditis............. *

Yes

No

High Blood Pressure *

Yes

No

Herpes______________ *

Yes

No

Diabetes......... _____................ *

Yes

No

Low Blood Pressure *

Yes

No

Heart Attack................... *

Yes

No

Epilepsy..................................... *

Yes

No

Seizures *

Yes

No

Hives/Skin Rash............ *

Yes

No

Anemia.............> > > > >.......... *

Yes

No

AIDS................ *

Yes

No

Arthritis.......................... *

Yes

No

Rheumatic Fever..........> > > .. *

Yes

No

Tuberculosis *

Yes

No

Hepatitis......................... *

Yes

No

Stroke.....................> > >......... *

Yes

No

Asthma *

Yes

No

Hay Fever....................... *

Yes

No

Kidney Disease . . . . . . . . .. . . *

Yes

No

Jaundice *

Yes

No

Venereal Disease.......... *

Yes

No

Pacemaker . . . . . . . . . . . .. . *

Yes

No

Sinus Trouble *

Yes

No

Thyroid Problems . . . . . *

Yes

No

Active Infection . . . . . . . . . . *

Yes

No

Swollen Neck Glands *

Yes

No

Depression . . . . . . . . . . *

Yes

No

Deviated Septum . . . . . . . . . *

Yes

No

Osteoperosis *

Yes

No

Frequent Headaches . . *

Yes

No

Other

Yes

No

If 'Other', Please Explain:

Have you ever taken a bisphosphonate such as Fosamax, Actonel, or Boniva? *

Yes

No

Have you been told you snore occassionally? *

Yes

No

Do you wish you slept better and had more energy? *

Yes

No

Have you been prescribed or do you use a CPAP? *

Yes

No

Do you feel tired throughout the day? *

Yes

No

Women Only

Women who take oral contraceptives (birth control pills) should take extra precautions when taking antibiotics because antibiotics can cause failure of birth control pills which can result in pregnancy.

Are you pregnant or suspect that you may be pregnant?

Yes

No

Are you taking oral contraceptives (birth control pills)?

Yes

No

If you use other types of birth control medications that are not pills (such as Depo shots), please list them below: *

CREDIT CARD ON FILE AGREEMENT

Triangle Family Dentistry is implementing a new credit card on file policy effective February 2023. Like many other dental and medical practices, we have adopted a similar policy. We kindly request our patient’s guardian/guarantor provide a credit card which will be used to pay a balance. Co-pays are still due at the time of service. Your credit card information will be obtained and kept securely on file.

After your claim is paid, we will process your card on file for any balances less than $100.00 and send you a receipt for the charge. For balances over $100.00, you will receive an electronic statement, and your prompt payment is expected within 7 days. You may call our office if you have questions about your balance.

This “Card-on-File” policy simplifies payment for you, and it reduces paperwork, ultimately helping lower the cost of care. Our Guest Support team is always available to answer questions about the Credit Card on File payment method or any balances due.

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By signing below, I authorize Triangle Family Dentistry to keep my signature and my credit card information securely on-file in my account. I authorize Triangle Family Dentistry to charge my credit card for any outstanding balances equal to or less than $100.00.

Credit Card Type:

VISA

Mastercard

Discover

American Express

Name on Card:

Cardholder Relationship to Patient:

Last 4 Digits of CC#:

CC Expiration:

*Please be advised, if the credit card on file differs from the CC info provided above, we will use the CC on file.*

Please list any person(s) you authorize this CC for:

1) Authorized User Full Name

DOB:

2) Authorized User Full Name

DOB:

3) Authorized User Full Name

DOB:

Card Holder's Signature *

clear

Date: +

Dental Questionnaire

My current dental goals are:

I have read and understand the above questions. I have answered all of these questions truthfully to the best of my ability and knowledge.

Signature *

clear

Today's Date (MM/DD/YYYY) * +

Thank you for taking the time to complete this form.

We personalize your dental care based on the answers you’ve provided.

Apex - Green Level	Apex - Kelly Rd	Brier Creek
Cary Park	Fuquay-Varina	Heritage Branch
Morrisville	Rolesville	WF - Rogers Rd

Whiter Teeth	Full Dentures	Partials
Pain Free	Cavity free	Better chewing
Straighter Teeth	Better Breath	Sedation Dentistry
Healthier gums	Less Bleeding	Stop Snoring
Replacing Missing Teeth	Decrease Sensitivity