Form - Tupelo Dental Group

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Our Practice
Patient Forms
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1Patient Information

2Primary Insurance

3Dental History

4Medical History

5Signature

Today's Date
MM slash DD slash YYYY
Name
First Middle Last
Phone
Social Security Number
Birthdate
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Sex
- Male
- Female
Status
- Minor
- Single
- Married
- Divorced
- Separated
- Widowed
Patient Employer
Occupation
Business Phone
Employer's Address
Street Address City State ZIP Code
Emergency Contact
Relationship
Phone
How did you hear about us?

Person Responsible for Account
First Middle Last
Relationship
Phone
Social Security Number
Date of Birth
MM slash DD slash YYYY
Address (if different)
Street Address City State ZIP Code
Employer
Occupation
Business Phone
Employer Address
Street Address City State ZIP Code
Insurance Company
Policy Number
Group Number
Subscriber Number
Names of Other Dependents
If you have additional insurance, please notify the front desk.

Reason for Today's Visit
Date of Last Dental Exam
MM slash DD slash YYYY
Former Dentist
Date of Last Dental X-Rays
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Place a check mark in the box if you have had problems with any of the following:
- Discomfort, clicking or popping in jaw
- Red, swollen, or bleeding gums
- Sensitive tooth, teeth, or gums
- Blisters, sores in or around mouth
- Lost/broken fillings
- Teeth grinding
- Ringing in ears
- Broken/chipped tooth
- Stained teeth
- Locking jaw
- Bad breath
- Other
Other Problems
How often do you floss?
How often do you brush?

Do you have any heart conditions that require pre-medication?
- Yes
- No
Cardiologist Name
Do you have any joint replacements that require pre-medication?
- Yes
- No
Surgeon Name
Have you every taken:
- Bisphosphonates (ex: Aredia/Fosamax)
- Phen-fen/Redux
- None
Are You Pregnant?
- No
- Yes
Are You Nursing?
- No
- Yes
Are You Taking Birth Control?
- Yes
- No
Do You Use Tobacco Products?
- No
- Yes
How Much/Long?
Place a check mark in the box if you have or have had any of the following:
- Anemia
- Arthritis/Rheumatism
- Artificial Heart Valves
- Artificial Bones/Joints
- Asthma
- Back Problems
- Blood Disease
- Cancer/Tumors
- Chemical Dependency
- Chemotherapy
- Circulatory Problems
- Cortisone Treatments
- Cough, Persistent
- Cough Up Blood
- Diabetes
- Epilepsy/Seizures
- Fainting
- Headaches/Migraines
- Heart Murmur
- Heart Problems
- Hemophilia
- Hepatitis
- High Blood Pressure
- HIV+/AIDS/ARC
- Jaw Pain
- Kidney Problems
- Liver Problems
- Low Blood Pressure
- Mitral Valve Prolapse
- Pacemaker
- Radiation Treatment
- Respiratory Problems
- Rheumatic Fever
- Scarlet Fever
- Shortness of Breath
- Sinusitis/Sinus Problems
- Skin Rash
- Stroke
- Swelling of Feet or Ankles
- Thyroid Problems
- Tonsillitis
- Tuberculosis
- Ulcer
- Other
Other
List medications you are currently taking
Allergies
List any surgeries or medical conditions you have or ever had

• I authorize my insurance company to pay to Tupelo Dental Group, all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

• I authorize the dentist to release all information necessary to secure the payment of benefits.

• I understand that I am financially responsible for all charges whether or not paid by insurance.
Signature
Date
MM slash DD slash YYYY
Signer Is:
- Adult Patient
- Parent or Guardian
- Spouse
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Contact Us

Call 662.844.7231 or request an appointment today!

tupelodentalgroup@gmail.com

105 Parkgate Drive
Tupelo, MS 38801

Fax: 662.844.0142

Name*
Phone*
Email*
Message*
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Our Dentists

Peter West, DDS

Sanders West, DMD

Chris Hester, DMD

Hours

Monday thru Thursday
8am – 4pm

Friday
8am – 3pm

Emergency services are available.

We Accept

Cash, personal check, and all major credit cards

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Our Practice
Patient Forms
Contact Us

Our Practice
Patient Forms
Contact Us

Our Practice
Patient Forms
Contact Us

Our Practice
Patient Forms
Contact Us

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