(405) 624-3685
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Patient Information
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New Patient Form

Please fill this form out online and click submit prior to your appointment, or print out for your convenience.

Patient Form

About You
Referred By:
Name:*
First Name Middle Initial Last Name
Male/Female
- Male
- Female
Date of Birth:
MM slash DD slash YYYY
Marital Status:
Email:
Social Security #:
Driver’s License:
Home Phone:
Cell Phone:
Address:
Street Address City State / Province / Region ZIP / Postal Code
Employer:
Occupation:
Work Phone:
Employer’s Address:
Street Address City State / Province / Region ZIP / Postal Code
Person Responsible for Account if Other than Patient
Name:
Relation to Patient:
Phone:
Date of Birth:
MM slash DD slash YYYY
Social Security #:
Employer:
Address
Street Address City State / Province / Region ZIP / Postal Code
Emergency Contact:
Relation to you:
Phone:
Insurance Information
Policy Holder:
Policy Holder Date of Birth:
Policy Holder’s Employer:
Policy Holder’s ID #:
Group #:
Insurance Company:
Insurance Phone Number:
Insurance Company Address:
Street Address City State / Province / Region ZIP / Postal Code
Secondary Insurance Company:
Policy Holder:
Policy Holder’s Date of Birth:
Policy Holder’s ID #:
Group #:
Insurance Company Address:
Street Address City State / Province / Region ZIP / Postal Code
Insurance Company Phone:
Policy Holder’s Employer
Payment is Due at Time of Service
I understand that I am responsible for payment of services rendered by Dr. Jennifer Lauvetz-Enmeier, and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the office of Dr. Jennifer Lauvetz-Enmeier to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
Signature:
Date:
MM slash DD slash YYYY
Dental History
What concerns you most?
Are you having discomfort at this time?
What isthe discomfort?
How long since you have been to a dentist?
Did you have X-Rays?
Are your teeth sensitive to:
- heat?
- cold?
- sweet?
- sour?
- pressure?
How often do you brush your teeth?
How often do you use dental floss?
Do you have bleeding gums?
Have you ever had gum treatment?
When?
Do you grind or clench your teeth?
Do you hear popping or clicking noises when you chew?
Do you have any pain around either of your ears?
Any swelling or lumps in your mouth?
Do you have any fear of dental treatment?
How do you feel about the appearance of yourteeth?
Do you snore or have trouble sleeping at night?
Medical History
Are you currently under a Physicians care?
Physician’s Name:
Physician’s Address
Physician’s Phone
Do you or have you experienced any of the following? (Please circle Y/N)
- Abnormal Bleeding
- Alcohol Use
- Anemia
- Artificial Bones/Joints
- Artificial Valves
- Asthma
- Cancer
- Chemotherapy
- Colitis
- Congenital Heart Defect
- Diabetes
- Emphysema
- Fever Blisters
- Glaucoma
- Headaches
- Heart Attack
- Heart Murmur
- Heart Surgery
- Hemophilia
- Hepatitis
- Herpes
- High Blood Pressure
- HIV+/AIDS
- Kidney Problems
- Liver Disease
- Lupus
- Pacemaker
- Radiation Treatment
- Seizures
- Tobacco Use (Smoke/Chew
- Tuberculosis (TB)
- Venereal Disease
Please list any serious medical condition(s) that you have experienced:
Are you allergic to any of the following? (Please circle Y/N)
- Aspirin
- Barbiturates
- Codeine
- Dental Anesthetics
- Erythromycin
- Jewelry/Metals
- Latex
- Penicillin
- Sedatives
- Sulfa Drugs
- Tetracycline
- Other
Please list additional drugs/materials that cause allergic reactions:
Please list any and all medications you are currently taking:
For Women: Are you taking birth control pills?
Are you pregnant?
Week #:
Are you nursing?
Authorization
I affirm that the information I have given is correct to the best of my knowledge. All information herein will be held in the strictest confidence and it is my responsibility to inform Dr. Jennifer Lauvetz-Enmeier and staff of any changes in my medical status. I authorize dental staff to perform the necessary dental services I may need (including x-rays, photographs, study models, or any aids deemed appropriate) to make a thorough diagnosis of my dental needs.
Signature:
Date:

CALL: (405) 624-3685

EMAIL: info@amazingsmilesstillwater.com

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Treatments

Crowns
Dental Sealants
Dentures and Partials
Dental Implants
Fillings
Sleep Apnea
Tooth Extractions

“Best dentist experience I have ever had! The staff will treat you like royalty. They offer blankets if you’re cold and if you’re like me and super tense you can even get a hand massage! Dr. Lauvetz Enmeier even calls me personally after procedures to make sure I’m doing okay. Won’t go anywhere else!”

- Shae W.

APPOINTMENTS

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OR CALL: (405) 624-3685 or
EMAIL: info@amazingsmilesstillwater.com

Dr. Jennifer Lauvetz-Enmeier, D.D.S.
816 South Pine, Stillwater, OK 74074
(405) 624-3685

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