New Patient Forms

Welcome to Sugar Land Dental
Please complete this entire front page. (PLEASE PRINT)
Date

MonthDayYear
Mr. Ms. Mrs. Dr.
Patient's Name

Last NameFirst NameMiddle Initial
Preferred Name
Home Address
Apt#
City
State
Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Date Of Birth

MonthDayYear
Date
Sex

MF
Social Security Number
Driver's Licence Number
Place of Employment
Employment Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Insurance:
Insurance Phone Number:
Please enter a valid phone number.
Policy Holder's First and Last Name:
Policy Holder's Date Of Birth:

MonthDayYear
Date
Policy Holder's Social Security Number:
Emergencies: Name and phone of closest relative to patient:
Name
Phone
Please enter a valid phone number.
How did you hear about our office?
If patient is a minor, please complete this following information:
Responsible Person's Last Name
First Name
Middle Initial
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Social Security Number
D.O.B.

MonthDayYear
Date
Driver's License Number
Relationship To Patient
Place of Employment
Medical History
Are you under a physician's care now? Why?
Phone
Please enter a valid phone number.
YesNo
Have you ever been hospitalized or had a major operation? Discuss
YesNo
Have you ever had a serious injury to your head or neck? Discuss
YesNo
Are you taking any medications, pills or drugs?
YesNo
Are you on a special diet? Discuss
YesNo
Do you smoke or use smokeless tobacco or have smoked in the past? How much per day
What Type:
YesNo
Are you allergic to any medications or substances? Please check below
YesNo
AspirinPenicillinCodeineNovocaineAcrylicMetalLatex RubberOther
WOMEN Please check:

Pregnant/ Trying to get pregnant;
How far along if pregnant; Nursing;
Taking oral contraceptives;YesNo
Do you now have or have your ever had any of the folllowing? Please check if appropriate.

Heart MurmurMiral Valve ProlapseRheumatic FeverHeart SurgeryArtificial Heart ValueArtificial Joint/ImplantHeart TroubleHyprothyroidStrokePacemakerHigh Blood PressureLow Blood PressureBlood DiseaseAnemiaGlaucomaHyperthyroidHemophiliaLeukemiaBlood TransfusionLung DiseaseBreathing ProblemsAsthmaEmphysemaEpilepsy/ SeizureTumors/ GrowthsRecurrent InfectionsCancerRadiationChemotherapyDiabetesPsychiatric CarePain in jaw jointsLiver DiseaseHepatitis A,B or CKidney DiseaseVenereal DiseaseImmune DeficienciesHIV PositiveTuberculosisHigh Cholesterol
Have you ever had any other serious illness not checked above?

YesNo
Do you wish to talk to the dentist privately about any problems?

YesNo
To the best of my knowledge, all of the preceding answers are correct. If i have any changes in my health status or if any medicines change. I shall inform the dentist and staff at the next appointment without fail.
Patient Signature(parent or guardian if the patient is a minor)

Clear
Date

MonthDayYear
Date
To be completed by doctor:
Reviewed by Doctor:
Date

MonthDayYear
Date
BP
History Review and Significant Findings
Should be Empty:

Welcome to Sugar Land Dental

Medical History