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Health History Form
Save time at the office and fill out your new patient forms online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment.
Patient Information
Patient Name
Prefix
First Name
Last Name
Preferred Name
Date of Birth
-
Month
-
Day
Year
Date
Legal Guardian #1 (if patient is a minor)
Prefix
First Name
Last Name
Legal Guardian #2 (when applicable)
Prefix
First Name
Last Name
Primary Phone
Secondary Phone
Patient Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
E-mail
example@example.com
Gender
Please Select
Male
Female
Other
Prefer not to say
Whom may we thank for referring you to our office?
Other family members seen by us
Emergency Contact Information
Emergency Contact Name (different than primary)
First Name
Last Name
Relationship to Patient
Emergency Contact Phone #
Please enter a valid phone number.
Back
Next
What School or School District Does Patient Attend?
Back
Next
Dental Insurance Information
Primary Policy Holder Information
Primary DENTAL Insurance Information (if you do not have dental coverage, please type "N/A" for these sections)
*
Please type information below:
DENTAL Insurance Company Name
Policy Holder Full Name
Policy Holder Birthdate
Policy Holder Phone Number
Policy Holder Email
Member ID ( Must be filled)
Group Number
Employer (please type "private plan" if insurance is not through your employer)
Insurance Company Phone Number
Social Security Number (Must be filled)
Please only fill out this portion if you have dual DENTAL coverage:
Please provide information
Do you plan on using dual dental coverage?
If yes, please provide insurance company name.
If policy holder is different, please provide name
Policy Holder Birthdate
Member ID
Group Number
Insurance Company Phone Number
Social Security Number
Medical History
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Primary Care Physician
First Name
Last Name
Approx. Date of Last Visit
-
Month
-
Day
Year
Date
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician Phone Number
List of medications
Are you allergic to any medication?
Please Select
Yes
No
If yes, please explain
Do you have a history of any major illness?
Please Select
Yes
No
If yes, please explain
Have you had any major operations?
Please Select
Yes
No
If yes, please explain
Have you ever been involved in a serious accident?
Please Select
Yes
No
If yes, please explain
Please check any of the following that you have had or currently have:
If other, please explain:
Dental History
General Dentist
First Name
Last Name
Suffix
Dentist Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dentist Phone Number
Please enter a valid phone number.
Approx. Date of Last Visit
-
Month
-
Day
Year
Date
What concerns you most about your teeth?
Please check all that apply to your dental experience(s)
Additional comments:
Date
-
Month
-
Day
Year
Date
Signature
Full Name
First Name
Last Name
Submit
Should be Empty: