Please Fill Out The Forms Only When The Appointment Is Scheduled.
New Patient Registration and Dental History
Please do not print the forms. Submit the forms online only.
Title
Please Select
Mr.
Mrs.
Ms.
Dr.
Patient Name
*
First Name
Middle Name
Last Name
Preferred Name
Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Gender
*
Please Select
Male
Female
Marital Status
Please Select
Single
Married
Divorced
Widowed
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Landline Number
-
Area Code
Phone Number
Work phone Number
-
Area Code
Phone Number
Mobile Number
*
-
Area Code
Phone Number
Email Address
example@example.com
The following is for
Please Select
The Patient.
The person responsible for payment.
Employer
Address
(City, State, Zip, APT#)
Phone Number
-
Area Code
Phone Number
Whom may we thank for referring you to our practice?
In an emergency who should be notified?
His / Her Name
*
Phone Number
*
-
Area Code
Phone Number
Dental History
How would you rate the condition of your mouth?
*
Excellent
Good
Fair
Poor
Describe
*
Previous Dentist name and How long you have been a patient there
Date of most recent dental exam
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of most recent dental X-rays
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I routinely see my dentist every
3 Months
4 Months
6 Months
12 Months
Not routinely
What is your immediate concern?
Personal History. Check all the apply.
Had an unfavorable dental experience
Had any reactions to local anesthetic
Had your bite adjusted
Had complications from past dental treatment
Had trouble getting numb
Had/Have braces, orthodontic treatment
Had any teeth removed
If any of the checked boxes need further explanation, Please Describe
Signature
*
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
(Your digital signature (full name) is as legally binding as a physical signature.)
Submit
Should be Empty: