New Patient Form

Patient Information

Name:
Sex:
Date of Birth:
If minor, Parent(s)/Guardian(s) Name(s):
Driver's License #:
Social Security Number:
Email:
Address:
City, State, Zip:
Cell Phone:
May we leave a message:
Home Phone:
May we leave a message:

Emergency Contact

Emergency Contact Name:
Relationship:
Phone Number:
Whom may we thank for referring you to our office:

Insurance Information

Dental Insurance Company:
Employer:
Group Number:
Phone Number:
Subscriber's Name:
Subscriber ID Number/Social Security Number:
Secondary Dental Insurance Company:
Employer:
Group Number:
Phone Number:
Subscriber's Name:
Subscriber ID Number/Social Security Number:

Medical Information

Do you currently/have you ever had any of the following:
Active Tuberculosis
Peristant cough greater than 3 weeks
Cough that produces blood
Been exposed to anyone with Tuberculosis?
 

IF YOU RESPONDED YES TO ANY OF THESE 4 ITEMS ABOVE, PLEASE STOP AND CONTACT OUR OFFICE DIRECTLY

Physician Name:
Phone Number:
City:
State:
Date of last physical exam:
Height:
Weight:
Have you been hospitalized in the past 5 years? If yes, why?:
Please list ALL meciations (prescribed and over the counter):
Are you in overall good health? If no, please explain what is being treated:
Do you have any history of the following?:
Bladder Issues:
Contact Lenses:
Premedication for dental treatment:
Arthritis:
Chicken Pox:
Cancer:
Sleep Apnea:
Ear Aches:
Growth Problems:
Hepatitis:
Liver Disease:
Rheumatic Fever:
Thyroid Problems:
Bone/Joint Disorders:
Eating Disorder:
High/Low Blood Pressure:
Asthma:
Chronic Sinusitis:
Sleep Disorder:
Osteoporosis:
Epilepsy:
Hearing Loss:
HIV +/Aids:
Measles/Mumps:
Seizures:
Tobacco/Drug Use:
Artificial Joints/Heart Valves:
Congestive Heart Failure:
Anemia:
Cerbral Palsy:
Bleeding Disorders:
Snoring:
Diabetes:
Fainting:
Heart Conditions:
Kidney Disorders:
Pregnancy/Nursing:
Sickle Cell
STD/Venereal Disease
Are you allergic to or have you ever had a reaction to: (If yes, please describe reaction)
Local Anesthetics:
Penicillin or other anibiotics:
Aspirin:
Sulfa Drugs:
Codeine or other narcotics:
Iodine:
Latex:
Metals:
Hay Fever/Seasonal:
Animals:
Food:
Any other allergies:

Dental Information/History

Bleeding Gums:
Tooth Sensitivity:
Dry Mouth
Periodontal Gum Treatment/Surgery
Orthodontic Treatment
Problems with past dental treatment:
Drink Fluoridated Water:
Drink Bottled/Filtered Water:
Dental Pain/Discomfort:
Earaches/Neck Pains:
Clicking/Popping/Discomfort in the Jaw Joint:
Grind your teeth:
Sores/Ulcers in your mouth:
Wear Dentures/Partials:
Serious Injury to head/neck/mouth:
Reason for today's visit:
Date of last dental exam:
Date of last dental x-rays:
Is there anything else the Doctor should know about your health? If YES, please explain in detail:
I will discuss any and all relevant patient health issues with the provider prior to any dental treatment.
Initial:

I certify that I have read and understand the above and that the information given on this form is true and 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, 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.

Signature of Patient/Legal Guardian:
Relationship to Patient (if applicable):
Today's Date:

Once completed, please print off this form and bring it in for your upcoming dentist appointment – Thanks