CO - New patient form

Name *

First Name Last Name
DOB *

Month Day Year
Date
Sex *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Primary phone # *
Please enter a valid phone number.
Secondary phone #
Please enter a valid phone number.
Emergency phone #
Please enter a valid phone number.
Do you currently see a General Dentist? *
Dentist name
When was your last visit?

Month Day Year
Date
How did you find out about us?
What is your main concern with your teeth
Responsible Party Information
Responsible Party *
Name *

First Name Last Name
Relationship(to patient *
Sex *
Primary Phone *
Please enter a valid phone number.
Email *
example@example.com
Dental Insurance Information
Do you have dental insurance?
Policy Holder's Name *
DOB *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company *
Insurance Phone # *
Please enter a valid phone number.
Employer *
Group # *
Social Security # or ID # *
Patient History
Are you in good health? *
Has there been any change in your general health in the past year? *
Date of last physical exam? *

Month Day Year
Date
Are you now under a physician’s care? *
Example *
Have you ever had any serious illnesses,Operations of hospitalizations? If so, describe
DO YOU HAVE OR HAVE EVER HAD *

A. Rheumatic Fever or Heart Disease? B. Congenital Heart Disease? C. Cardiovascular Disease (Heart Attack,Heart Trouble, Heart Murmur, Coronary Artery Disease, Angina, High Blood Pressure, Stroke,Palpitations, Heart Surgery, Pacemakers)? D. Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis,Shortness of Breath, Chest Pain, Sever Coughing)?E. Seizures, convulsions, Epilepsy, Fainting or Dizziness? F. Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? G. Liver Disease (Jaundice, Hepatitis)? H. Kidney Disease? I. Diabetes? J. Thyroid Disease? K. Arthritis? N. Implants placed anywhere in your body (Heart valve, Pacemaker, Hip or Knee)? O. Radiation (x-ray) treatment for cancer? P. Sinus or Nasal Problems? Q. Any disease, drug or transplant operation that has depressed your immune system? None
ARE YOU USING ANY OF THE FOLLOWING? *

A. Antibiotics? B. Anticoagulants (Blood Thinners)? C. Aspirin or Ibuprofen? D. High Blood Pressure medications? E. Steroids? F. Tranquilizers? G. Insulin or Oral Anti-Diabetic Drugs? H. Digitalis, Inderal, Nitroglycerin or otherheart Drugs? I. Are you taking or have you ever taken Bisphosphonates (Fosamax, Actonel, Zometa,Bondronat, Aredia, Didronel, Bonefos, Loron, Skelid, Neridonate, Olparonate) for osteoporosis? None
Please list any and all medications taken, Including prescription medications, over-the-Counter medications, herbal or holistic remedies, Vitamins or minerals.
ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION TO: *

Local Anesthesia (Novocain, etc.)? Penicillin or other antibiotics? Sedatives or Barbiturates? Aspirin or Ibuprofen? Latex or Rubber Products? Other allergies or reactions? Please list. None
Allergies or reactions (please describe)
Do you smoke, chew tobacco or vape? *
How much per day?
# of years
Any past history of Alcohol or Chemical Dependency or Emotional Disorder? *
Have you had any serious problems associated with any previous dental treatment? *
Have you or an immediate family‘member had any problem associated with General Anesthesia? *
Do you have any other disease,condition or problem not listed above that you think the Doctor should know about? *
FOR WOMEN ONLY:

Is there a chance you could be pregnant? Are you nursing?
Extra information
Type a question
Signature *

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Responsible Party Information

Dental Insurance Information

Patient History