NEW PATIENT FORM

1) Would you consider yourself to be in fairly good health?

YesNo

2) When was your last medical checkup?

3) Have you ever had complications following dental treatment?

YesNo

4) Are you currently being treated for any medical condition or have been treated within the past year?

YesNo

If Yes, please explain

5) Have you been hospitalized within the last 5 years due to a surgery or illness?

YesNo

6) Do you use tobacco (smoking or chewing or vaping)?

YesNo

7) Do you use corrective lenses (contacts or glasses)?

YesNo

8) Do you have any other conditions, diseases, etc. not listed below that we should be aware of?

YesNo

If yes, please list them

9) Are you taking any medications, non-prescription drugs, natural supplements of any kind?

YesNo

If yes, please list them.

10) Please indicate if you have experienced any of the following:

WOMEN ONLY: Are you pregnant?

YesNo

WOMEN ONLY: Are you nursing?

YesNo

11) When was your last visit to the dentist?

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?

YesNo

15) Do your teeth experience sensitivity to cold or hot temperatures?

YesNo

16) Are any of your teeth currently causing you pain?

YesNo

17) Do you grind your teeth (either consciously or during sleep)?

YesNo

18) Are any of your teeth loose, or are you concerned about any teeth loosening?

YesNo

19) Do you currently have any dental implants, dentures, or partials?

YesNo

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).

Print Name:*

Date*

Date

Signature*

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Relationship to Patient:

NEW PATIENT FORM

IF UNDER 18 OR UNDER GUARDIANSHIP:

PRIMARY CARE PHYSICIAN INFORMATION:

EMERGENCY CONTACT INFO INFORMATION:

INSURANCE INFORMATION:

Please fill below if you have any additional insurance:

MEDICAL & DENTAL HISTORY FORM

AUTHORIZATION

Signature of patient, parent, or guardian: