NEW PATIENT FORM

  • NEW PATIENT FORM

  • Date of Birth (D/M/Y)*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • IF UNDER 18 OR UNDER GUARDIANSHIP:

    (please complete all information if different than above)
  • Format: (000) 000-0000.

  • PRIMARY CARE PHYSICIAN INFORMATION:

  • Format: (000) 000-0000.

  • EMERGENCY CONTACT INFO INFORMATION:

  • Format: (000) 000-0000.

  • INSURANCE INFORMATION:

    (if applicable)
  • Do you have insurance?
  • Date of Birth
     / /
  • Format: (000) 000-0000.

  • Please fill below if you have any additional insurance:

  • Date of Birth
     / /
  • Format: (000) 000-0000.

  • MEDICAL & DENTAL HISTORY FORM

  • 1) Would you consider yourself to be in fairly good health?
  • 3) Have you ever had complications following dental treatment?
  • 4) Are you currently being treated for any medical condition or have been treated within the past year?
  • 5) Have you been hospitalized within the last 5 years due to a surgery or illness?
  • 6) Do you use tobacco (smoking or chewing or vaping)?
  • 7) Do you use corrective lenses (contacts or glasses)?
  • 8) Do you have any other conditions, diseases, etc. not listed below that we should be aware of?
  • 9) Are you taking any medications, non-prescription drugs, natural supplements of any kind?
  • 10) Please indicate if you have experienced any of the following:
  • WOMEN ONLY: Are you pregnant?
  • WOMEN ONLY: Are you nursing?
  • 12) How frequently do you brush your teeth?
  • 13) How frequently do you floss your teeth?
  • 14) Do your gums bleed when you brush or floss?
  • 15) Do your teeth experience sensitivity to cold or hot temperatures?
  • 16) Are any of your teeth currently causing you pain?
  • 17) Do you grind your teeth (either consciously or during sleep)?
  • 18) Are any of your teeth loose, or are you concerned about any teeth loosening?
  • 19) Do you currently have any dental implants, dentures, or partials?

  • AUTHORIZATION

  • I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health. If I ever have a change in my health, I will inform the office at my next dental appointment

    I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

    I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balances on my account.

    I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

  • Signature of patient, parent, or guardian:

  • Date*
     / /
  •  
  • Should be Empty: