Address:
South Jordan
11677 S 4000 W
South Jordan, UT 84009

Provo
3610 North University Avenue, Suite 150
Provo, UT 84604

Payson
1107 South Highway 198
Payson, UT 84651

Lehi
139 N Hunters Grove Ln, Ste 150
Lehi, UT 84043

Phone:
(801) 938-3412 - South Jordan
(801) 356-2226 - Provo
(801) 356-2226 - Payson
(801) 901-8089 - Lehi

Section 1 of 4 in this document

Page 1 of 3

General Patient Information

Today's Date

Full Name

Gender

Male

Female

Marital Status

Married

Widowed

Single

Separated

Divorced

Date of Birth

Age

SSN

Address

Apt

City

State

Zip

Mobile Phone

Work Phone

Home Phone

Occupation

Employer

Employer Address

Preferred Pharmacy

How did you find us?

Referring Doctor

(If patient is over 18 y/o and a full time student):

Name of School

City

Family members seen at this office

Emergency Contact Information

Emergency Contact

Relationship to Patient

Contact Mobile Phone

Contact Home Phone

Contact Email

Section 2 of 4 in this document

Page 2 of 3

Responsible Party Information (Financial)

Full Name

Gender

Male

Female

Date of Birth

SSN

Address

Apt

City

State

Zip

Mobile Phone

Home Phone

Work Phone

Occupation

Employer

Insurance Information

Primary Dental Insurance

Primary Dental Phone

Primary Dental Address

Primary Dental Policyholder Employer

Primary Dental Policyholder Name

Primary Dental Policyholder DOB

Primary Dental Policyholder Relationship

Primary Dental Policy ID

Primary Dental Group ID

Primary Medical Insurance

Primary Medical Address

Primary Medical Phone

Primary Medical Policyholder Employer

Primary Medical Policyholder Name

Primary Medical Policyholder Relationship

Primary Medical Policyholder DOB

Primary Medical Policy ID

Primary Medical Group ID

Secondary Dental Insurance

Secondary Dental Phone

Secondary Dental Address

Secondary Dental Policyholder Employer

Secondary Dental Policholder Name

Secondary Dental Policyholder DOB

Secondary Dental Policyholder Relationship

Secondary Dental Policy ID

Secondary Dental Group ID

Secondary Medical Insurance

Secondary Medical Phone

Secondary Medical Address

Secondary Medical Policyholder Employer

Secondary Medical Policyholder Name

Secondary Medical Policyholder DOB

Secondary Medical Policyholder Relationship

Secondary Medical Policy ID

Secondary Medical Group ID

Document Signers

- Patient

General Patient Information

Gender

Marital Status

Emergency Contact Information

Responsible Party Information (Financial)

Gender

Insurance Information

Medical History

Allergies

Are you now under the care of a physician

Do you have any of the following diseases of problems?

Have you taken tranquilizers, sleeping pills, antidepressants, and/or narcotics on a regular basis

Have you had any serious illness, operation, or hospitalization in the last 5 years

Do you wish to talk with the doctor about anything privately

Are you taking any blood thinners (Coumadin®, Plavix®, aspirin, vitamin E, ginkgo biloba)

Have you had any serious problems associated with any previous dental treatment

Are you wearing a removable dental appliance

Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in/around mouth

Have you had an artificial joint replacement (knee, hip, shoulder, etc.)

Have you taken Bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers (Reclast®, Fosamax®, Boniva®, Actonel®, Boniva®, Aredia®, or Zometa®)

Are you wearing contact lenses

Women Only

Are you pregnant or trying to become pregnant

Do you have problems associated with your menstrual period

Are you nursing

Are you taking birth control pills

If this visit is related to an accident

If you are having surgery today

Ingested Food or Drink