New Patient Form

New Patient Form
Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.
Patient Name*

First NameLast Name
Sex*
Birthdate*

MonthDayYear
Date
Sports/Hobbies
School/Occupation
Person Responsible For Account
Name*

First NameLast Name
Relationship to Patient*
Marital Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Employer/Occupation
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Whom may we thank for referring you?
Emergency Contact

Not living with you
Name*
Relationship to Patient*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Medical History
Physician's Name*
Dentist's Name*
Please describe orthodontic concerns*
Has the patient been treated for orthodontics before?*

YesNo
Have any relatives had a protruding jaw or needed jaw surgery?*

YesNo
Have there been any injuries to the face, mouth, teeth, or chin?*

YesNo
Has the patient ever had any pain/tenderness in his/her jaw joint?*

YesNo
Has the patient ever had periodontal (gum) treatment?*

YesNo
If patient is a minor, has puberty begun?*

YesNoN/A
Do you pre-medicate before dental visits?*

YesNo
Has the patient ever taken osteoporosis medications or weight loss drugs?*

YesNo
If so, please list which medications
Please list all allergies (drugs, food, other)
Please list all medications patient is currently taking
Has the patient ever had any of the following?
Abnormal Bleeding*

YesNo
ADD/ADHD*

YesNo
Allergies*

YesNo
Allergy to Medications*

YesNo
Arthritis*

YesNo
Artificial Heart valves or joints*

YesNo
Asthma*

YesNo
Back or neck problems*

YesNo
Breathing problems*

YesNo
Cancer*

YesNo
Diabetes*

YesNo
Epilepsy*

YesNo
Headaches/Migraines*

YesNo
Hearing Impairment*

YesNo
Heart murmur/defect*

YesNo
Heart problems*

YesNo
Hemophilia*

YesNo
Hepatitis*

YesNo
Herpes (any type)*

YesNo
High blood pressure*

YesNo
HIV or AIDS*

YesNo
Kidney/Liver Problems*

YesNo
Psychological Counseling*

YesNo
Ringing in ears*

YesNo
Rheumatic/Scarlet Fever*

YesNo
Seizures*

YesNo
Sinus problems*

YesNo
Sleep Apnea*

YesNo
Speech problems*

YesNo
Swallowing problems*

YesNo
Tonsils/Adenoids removed*

YesNo
Tuberculosis*

YesNo
Ulcers*

YesNo
Any Handicaps/ Disabilities*

YesNo
Any operations*

YesNo
Does/Has the patient have/had any of the following habits?
Frequent gum chewing*

YesNo
Chew/Smoke Tobacco*

YesNo
Clenching/Grinding Teeth*

YesNo
Lip Sucking/Biting*

YesNo
Mouth Breather*

YesNo
Nail Biting*

YesNo
Thumb/Finger Sucking*

YesNo
Tongue Thrust*

YesNo
Signatures
Date*

MonthDayYear
Date
Patient/Parent/Guardian Signature*

Clear
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
Should be Empty:

New Patient Form

Person Responsible For Account

Emergency Contact

Medical History

Has the patient ever had any of the following?

Does/Has the patient have/had any of the following habits?

Signatures