FacebookTwitterBloggerYouTubeLinkedIN
 
 





 
 

Patient Forms - Patient Info Sheet  

Our goal is to help you reach and maintain maximum oral health. Please fill out the form completely. The better we communicate, the better we can care for you. Thank you and we are glad you are here!

If you would prefer to print out the form and bring it with you, click on the link below. Otherwise an online form has been provided below. Thank you for answering the following questions.

Patient Info Form (pdf)

About Patient

Today's Date: E-Mail Address: 
Patient's Name:Date of Birth: - -
 LastFirstMI MonthDayYear
Preferred Name:  Male  FemaleAge: 
Social Security Number:  -  - Home Number:() -
Home Address: Work Number:() -
City:  State:  Zip: Cell Number:() -
 Single  Married  Divorced  Widowed  Separated
Can we text appointment information to your cell phone:  Y  N
Employer Name: Occupation: 
Employer Address: How long employed there? 
City:  State:  Zip: How did you hear about us? 

Spouse Information

His/Her Name: Date of Birth: - -
Social Security Number:  -  - Cell Number:() -
Employer: Work Number:() -

Dental Insurance Information

Name of Employee: Employee's
Date of Birth:
- -
Employer Name: Patient's Relationship to the employee:
Employee's ID#: 
Insurance Co. Name: Group #:
Insurance Co. Address: Phone # for customer service:() -
City:  State:  Zip:  

Dental History

How many times per day do you brush your teeth? 
Do your gums ever bleed?  Yes  No
Do you floss your teeth?  Yes  No
Do you use mouthwash?  Yes  No
Have you had orthodontic treatment in the past?  Yes  No
Do you currently wear any retainers or night guards?  Yes  No
Do you have any dental concerns today?  Yes  No
If yes, what dental concerns do you have? 
How long since your last dental visit? 
Name of previous dentist? 
Why did you leave your last dentist? 

 
© Copyright 2010- Dr. Matthew T. Lenz DDS, www.lenzdds.com
All Rights Reserved
Web Development, Hosting and Maintenance provided by TakeCareOfMyWebSite.com