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Home
About Us
- Meet the Team
Our Services
Invisalign
For Patients
Insurance
Blog
Contact Us

New Patient Forms for Pecan Tree Family Dentistry

Streamline Your First Visit with Online Registration

book an appointment (972) 562-0767

Please fill in the forms to the best of your knowledge.

New Patient Forms (New)

Welcome to Pecan Tree Family Dentistry – Please Tell Us About Yourself

We feel privileged to be your dental provider.

First Name

Last Name

Date of Birth

Gender

Male

Female

My gender is not listed

Prefer not to answer

SSN

Marital Status

Single

Married

Divorced

Widowed

Separated

Domestic Partnership

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number (Home or Cell or Work)

Emergency Contact

Who may we contact in case of emergency.

Name

Relationship to You

Address

Phone

Who can we thank for referring you?

How did you hear about us?

General Dental Treatment Consent (Required)

I authorize the dental professionals at Pecan Tree Family Dentistry to perform any necessary x-rays, study models, photographs, or other diagnostic tests required to assess my (or my dependent’s) dental condition. I understand that these diagnostic tools are essential for an accurate diagnosis and treatment planning.

Upon completion of this assessment, I give consent for Pecan Tree Family Dentistry to proceed with any recommended treatments that have been mutually agreed upon, and to utilize additional assistance as necessary to ensure proper care. I understand that the recommended treatments will be explained to me, including their purpose, benefits, and any associated risks or alternatives.

I acknowledge and accept the general risks associated with dental procedures, including but not limited to infection, discomfort, and unexpected outcomes. I understand that while the dental professionals at Pecan Tree Family Dentistry strive to provide the highest standard of care, no guarantees can be made regarding the success or outcome of the treatment.

I understand that I have the right to ask questions and seek clarification about any aspect of my treatment plan. I also have the right to refuse any treatment or procedure, understanding that this may impact my oral health.

I certify that I have read and understood the information provided in this consent form. I consent to the use of my personal information for the purposes outlined above, and I agree to be bound by the terms and conditions set forth herein.

I consent and acknowledge that the above statements are accurate. Also, please type your name and date as your electronic signature to confirm the above:

First Name

Last Name

Today’s Date

Insurance Information – Primary

If you have dental insurance, please provide us with your dental insurance information. Please fill out as much information as possible.

Subscriber’s Name

Relationship to the Patient

Subscriber DOB

Subscriber SSN/ID

Subscriber Employer

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Group Number

Insurance Information – Secondary (Optional)

Subscriber’s Name

Relationship to the Patient

Subscriber DOB

Subscriber SSN/ID

Subscriber Employer

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Group Number

Assignment and Release (Required)

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Pecan Tree Family Dentistry all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

I consent and acknowledge that the above statements are accurate. Also, please type your name and date as your electronic signature to confirm the above:

First Name

Last Name

Today’s Date

Health History

Please provide us with your health history information. Please fill out as much as possible.

Do you currently have a physician who oversees your health and medical needs?

Your current physical health is…

Physician’s Name

Physician’s Phone Number

Physician’s Address

When was your last visit to a physician?

Are you taking or have you recently taken any prescription or over-the-counter medicine(s)?

If so, please list all, including vitamins, natural or herbal and/or diet supplements:

Have you had a serious illness, operation or been hospitalized in the past 5 years?

If so, what condition was being treated?

Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease?

If so, what condition was being treated, and for how long?

Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

If so, what condition was being treated, and for how long?

Do you use tobacco (smoking, snuff, chew, bidis)?

Do you use controlled substances (drugs)?

Do you drink alcoholic beverages?

Please indicate any allergies you may have.

Local anesthetics

Aspirin

Penicillin or other antibiotics

Barbiturates, sedatives, or sleeping pills

Sulfa drugs

Codeine or other narcotics

Metals

Latex (rubber)

Iodine

Hay fever/seasonal

If you marked any of the boxes above, please provide more details about the conditions you have or have had.

Please Check All Present or Past Medical Conditions

First Abnormal Bleeding

Alcohol Abuse

Anemia

Angina Pectoris

Arthritis

Artificial Heart Valve

Asthma

Autoimmune Disease

Blood Transfusion

Cancer

Chemotherapy

Colitis

Congenital Heart Defect

Diabetes Type I or II

Difficulty Breathing

Drug Abuse

Emphysema

Please Check All Present or Past Medical Conditions

Epilepsy

Facial Surgery

Fainting Spells

Fever Blisters

Frequent Headaches

Glaucoma

HIV + AIDS

Heart Attack

Heart Murmur

Heart Surgery

Hemophilia

Hepatitis A

Hepatitis B

Hepatitis C

High Blood Pressure

Joint Replacement

Kidney Problems

Please Check All Present or Past Medical Conditions

Liver Disease

Low Blood Pressure

Mitral Valve Prolapse

Pacemaker

Psychiatric Problems

Radiation Therapy

Rheumatic Fever

Seizures

Sexually Transmitted Disease

Shingles

Sickle Cell Disease

Sinus Problems

Stroke

Thyroid Problems

Tuberculosis

Ulcers

If Female, Please Answer

Birth Control Pill

Are you pregnant?

Are you nursing?

If you marked any of the boxes above, please provide more details about the conditions you have or have had.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

First Name

Last Name

Today’s Date