Kathy S. Hevrin D.D.S.

1788 Hwy 157 N Ste 101 Mansfield TX

New Patient Form

About you:

Today's Date:

Referred by:

Last Name:

First Name / Middle Initial:

What do you prefer to be called?

Your Gender:

Date of Birth:

What is your age?

Social Security #:

Mailing Address:

City, State, Zip:

Home Phone:

Cell Phone:

Work Phone:

Email :

Employer:

How Long?

Are you married? Yes No

If married, spouse Name:

Do you have Children? Yes No

How many?

Dental Insurance

Company Name:

Insurance company address:

Insurance city, state, Zip:

Insurance company phone:

Insurance ID:

Group Number:

Insured's Name:

Relation:

Insured's Date of Birth:

Insured's Employer:

In the Event of Emergency

Whom should we contact?

Relation:

Home Phone:

Work Phone:

Cell Phone:

Your Medical Doctor:

Doctor's Phone:

Dental Information

Reason for today's visit:

Exam

Emergency

Consultation

Any Pain? Yes No

If yes, how long:

Check the following problems

Medical History

What medications are you taking?

Nerve Pills
Pain Killers
Muscle Relaxers
Stimulants

Blood Thinners
Tranquilizers
Insulin
Osteoporosis Meds

Other Medications:

Have you ever taken Bisphosphates? Yes No

Have you ever taken Phen-fen/Redux? Yes No

Do you have, or have you had, any of the following diseases, medical conditions or procedures?

Surgeries and Other Medical Conditions:

Are you allergic to any of the following:

Latex
Aspirin
Dental Anesthetics

Tetracycline
Penicillin or Amoxicillin
Any Food Allergies

List Any Food Allergies:

Other Allergies:

Do you use tobacco? Yes No

If yes, how much?:

If yes, how long?

Rate your Health from 1 to 10:

Do you wear contact lenses? Yes No

For Women

Are you taking Birth Control pills? Yes No

How many children have you had?

Are you pregnant? Yes No

If yes, how long?

Are you nursing? Yes No