New Patient Information Welcome to the office of Dr. Pierce! Please read the below information before proceeding: Thank you for selecting us to provide dental care for you and your family. So that we may better serve you, please complete this questionnaire. The forms are protected with encryption , and all submitted information is confidential. To prevent loss of data, please do not use the forward or back buttons on your web browser. Make sure your information is correct before submitting. Submitting Information for Multiple Patients: If you are submitting information for more than one person, please fill out a unique form for every new patient. Once you complete each form, click the “Submit Another Patient’s Information” button to start a new patient form with the same address, billing, and insurance information.Patient InformationEmail* Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*How long at this address?*Choose oneLess than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsBirthdate* MM DD YYYY Social Security NumberIf patient is a minor, give parent's or guardian's name First Last EmployerWork PhoneOccupationTime Here*Choose oneLess than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsSpouse's Name First Last Spouse's Birthdate MM DD YYYY Spouse's Social Security NumberSpouse's EmployerSpouse's OccupationTime HereChoose one:Less than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsHow did you learn about our office?If you were referred by someone, whom may we thank?Responsible Party/Billing InformationName First Last Home PhoneWork PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long at this addressChoose oneLess than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsSocial Security NumberBirthdate MM DD YYYY Relationship to patientEmployerOccupationTime hereChoose oneLess than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsSpouse's Name First Last Spouse's Birthdate MM DD YYYY Spouse's Social Security NumberSpouse's EmployerSpouse's OccupationTime hereChoose oneLess than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsInsurance InformationInsured's Name First Last SSN or ID NumberInsurance CompanyGroup NumberInsurance PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have dual coverage?YesNoInsured's Name First Last SSN or ID NumberInsurance CompanyGroup NumberInsurance PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical HistoryWho is your primary care physician?Physician's PhoneHow would you describe your overall health?ExcellentGoodAverageFairPoorWhen was your last physical?Choose oneLess than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsHave you ever been hospitalized under a physician's care in the last two years?YesNoIf so, why?Please list all medications/drugs you are takingHave you ever had an adverse reaction or allergies to any medication or substance?(Please check if allergic.) Asprin Valium Sulfa Drugs Penicillin Novacaine Nitrous Oxide Codeine Iodine Tetracycline Erythromycin Xylocaine Latex OthersHave you had any past surgeries?Have you ever had any of the following?(Please check all that apply) Arthritis or Gout Artificial Joint Asthma or Allergies Bleeding Problem or Anemia Blood disease Blood Transfusion Bruise Easily Cancer Cold Sores Congenital Heart Problems Currently Pregnant Diabetes Dizziness or Fainting Drug/Alcohol Addiction Eating Disorder Emphysema Epilepsy or Seizures Fever Blisters Frequent Thirst Frequent Urination Glaucoma Heart Attack or Stroke Heart Murmur Heart Trouble Heart Valve or Pacemaker Hepatitis (A) Hepatitis (B) Hepatitis (C) Herpes High/Low Blood Pressure HIV-AIDS-ARC Hypoglycemia Jaw Joint Pain Kidney or Liver Disease Lung Disease Psychiatric Care Radiation/Chemotherapy Rheumatic Fever Sinus Problems Thyroid Problems Ulcers or G.I. Problems Use Tobacco X-ray/Chemotherapy Do you have any condition or problem not listed which we should know about? Please explainHave you ever been given antibiotics before dental treatment?YesNoHave you recently consumed alcohol?YesNohave you recently used recreational drugs?YesNoRecreational use combined with local anesthesia may cause a life-threatening emergency.Dental HistoryWhat are your current dental concerns?When was your last dental visit?Choose oneLess than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsWhen were your last dental x-rays?Choose oneLess than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsWhen was your last cleaning?Choose oneLess than 3 months3 - 6 months6 moths - 1 year1 year - 2 years2 years - 5 yearsMore than 5 yearsHave you avoided regular dental care?YesNoWhy?Do you feel you have active decay?YesNoDo you feel you have gum disease?YesNoHave you ever had gum treatments?YesNoHow often do you brush?Choose oneLess than once a weekOnce weeklySeveral times weeklyOnce a dayTwice a dayThree times a dayHow often do you floss?Choose oneLess than once a weekOnce weeklySeveral times weeklyOnce a dayTwice a dayThree times a dayHow often do you use other aids?Choose oneLess than once a weekOnce weeklySeveral times weeklyOnce a dayTwice a dayThree times a dayAre you happy with the appearance of your teeth?YesNoWould you like your teeth to be whiter?YesNoWhat are your dental expectations?Name of previous dentistCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificHow would you rate your previous dental experience?Choose oneExcellentGoodAverageFairPoorNearest RelativeName of nearest relative not living with you First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NameThis field is for validation purposes and should be left unchanged.