New Patient Form
Date
-
Month
-
Day
Year
SS #
Name
*
First Name
Last Name
Nickname/Preferred name
Patient's Birth date
-
Month
-
Day
Year
Email
example@example.com
Marital Status
Patient mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile #
*
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Preferred contact method
Best time to call
Emergency contact (person)
Emergency contact #
Please enter a valid phone number.
Occupation
Employer
Previous provider
Were you referred to this office?
Yes
No
If yes, name
Back
Next
Medical History
Allergies
Acetaminophen/Tylenol®
Acrylic
Aspirin
Codeine
Ibuprofen/Motrin®/Advil®
Iodine
Latex
Local anesthetic
Morphine
Penicillin
Sulfa
If none of the above, what you are allergic to?
Conditions
Abnormal/excessive bleeding
AIDS or HIV infection
Alzheimer's/dementia
Anemia
Angina
Anxiety
Arthritis
Asthma
Autoimmune disease
Back problems
Blood disease
Blood transfusion
Breathing problems/respiratory disease
Bronchitis
Cancer/chemotherapy/radiation treatment
Cardiovascular disease
Chest pain upon exertion
Chronic pain
Congestive heart failure
Damaged heart valves
Diabetes
Emphysema
Epilepsy
Fainting spells or seizures
Frequent headaches
Gastrointestinal disease
G.E. Reflux/persistentheartburn
Glaucoma
Heart rhythm disorder
Hemophilia
Hepatitis, jaundice or liverdisease
High blood pressure
Kidney problems
Low blood pressure
Mitral valve prolapse
Neurological disorders
Osteoporosis/Paget's disease
Other congenital heart defects
Pacemaker
Persistent swollen glands inneck
Psychiatric care
Recurrent Infections
Rheumatic fever
Rheumatic heart disease
Rheumatoid arthritis
Severe headaches/migraines
Sinus trouble
Stroke
Systemic lupus erythematosus
Thyroid problems
TMJ Disorder
Tuberculosis
Tumors or growths
Ulcers
Details
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Yes
No
If yes, the what for?
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
Yes
No
if yes, then what and the year
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Yes
No
if yes, what medication?
Do you use tobacco (smoking, snuff, chew, bidis)?
Yes
No
Do you have sleep apnea?
Yes
No
Are you pregnant?
Yes
No
If yes, months
Are you taking birth control or hormonereplacement?
Yes
No
Are you nursing?
Yes
No
MEDICATION INFORMATION
Have you ever taken FosaMax®, Boniva®, Actonel® or other medications containing bisphosphonates?
Yes
No
Are you taking any prescription or over-the-counter medicines?
Yes
No
PLEASE LIST ALL MEDICATION HERE
Consent for digital communications(Allows us to send information over text/email)
Yes
No
Acknowledged practice privacy practices (Allows us to keep your data but will not share it with anyone but you)
Yes
No
Acknowledged HIPAA regulations
Yes
No
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