Family Dentistry
Patient Information Form  
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Patient Information Form
Date Gender 
Patient Name   
   Last
  First    M.I.
Email: 
Social Security # Family Status 
Phone # 
HomeWork    Ext.
Best Time To Call 
Preferred Appointment Times  
Address     
Street Address
   Apartment #       City
    
      State      Zip Code
Health Information
Date Of Last Dental Visit: 
Reason For This Visit: 
Have you ever had any of the following? Please check those that apply:
AIDS          Liver Disease
Allergies        Mental Disorders
Anemia          Nervous Disorders
Arthritis          Pacemaker
Artificial Joints          Pregnancy
Asthma               Due Date: 
Blood Disease          Radiation Treatment
Cancer          Respiratory Problems
Diabetes          Rheumatic Fever
Dizziness          Rheumatism
Epilepsy          Sinus Problems
Excessive Bleeding          Stomach Problems
Fainting          Stroke
Glaucoma          Tuberculosis
Growths          Tumors
Hay Fever          Ulcers
Head Injuries          Venereal Disease
Heart Disease          Codeine Allergy
Heart Murmur          Penicillin Allergy
Hepatitis          Other 
High Blood Pressure          Other 
Jaundice
Kidney Disease
Have you ever had complications following dental treatment? 
If yes, please explain: 
Have you been admitted to a hospital or needed emergency care during the past two years?  If yes, please explain: 
Are you now under the care of a physician?                          
If yes, Please explain: 
Are you currently taking any prescription medications? 
Please list any prescription medications that you are currently taking: 
Please list any over-the-counter medications and/or herbal supplements that you are currently taking: 
Name of physician: 
Physician's phone # 
Do you have any health problems that need further clarification? 
If yes, please explain: 
By checking this box, I agree that to the best of my knowledge, all of the preceeding answers and information are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Signature (full name) of patient, parent or guardian: 
Today's date: 
Referral Information
Whom may we thank for referring you to our practice? 
Name of person or office referring you to our practice: 
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www.DrGoeringer.com  2007
Dr. Bruce M. Goeringer, D.D.S.
15 Lincoln Street, Dallas, PA 18612
Phone: (570) 675-3646

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