New Patient Form
Patient's Name:
*
Patient's Nickname:
Patient Gender:
*
Male
Female
Patient's Birthdate:
*
-
Month
-
Day
Year
Date
Patient's Street Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number (If different from Billing Party):
Please enter a valid phone number.
Patient's Email Address (If different from Billing Party):
example@example.com
Patient's General Dentist:
Date of Last Dental Visit:
-
Month
-
Day
Year
Date
Patient's School or Work:
Which method(s) would you prefer to receive notifications of your future appointments? Check all that apply.
Email
Phone
What activities do you enjoy?
What activities do you enjoy?
How did your hear about our office?
Billing Party Information
(Person financially responsible for making payments)
Billing Party's Name
Billing Parties Relationship to Patient:
Billing Party's Street Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Party's Cell Number:
Please enter a valid phone number.
Billing Party's Work Number:
Please enter a valid phone number.
Billing Party's Email Address:
example@example.com
Marital Status:
Single
Married
Widowed
Separated
Divorced
Dental Insurance Information
If you have Orthodontic insurance, please provide the following information so we can verify your benefits before your scheduled appointment.
Policy Holder's Name:
Policy Holder's Date of Birth:
-
Month
-
Day
Year
Date
Policy Holder's Social Security or Member Identification #
Policy Holder's Social Security or Member Identification #
Insurance Company Phone Number:
Please enter a valid phone number.
Policy Holder's Employer:
Group Number:
Medical History
Physician's Name:
*
Physician's Phone Number:
*
Please enter a valid phone number.
Have the patient ever had any of the following medical concerns? (Check all that apply)
*
Abnomal Bleeding
Anemia
Artificial Bomes / Joints / Valves
Arthritis
Asthma
Blood Transfusion
Cancer / Chemothrapy
Congenital heart defects
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy / Seizures / Fainting
Fever Blisters / Herpes
Glaucoma
Heart Attack / Stroke
Heart Murmur
Heart Surgery / Pacemaker
Hemophilia
Hepatitis
High / Low Blood Pressure
HIV+ / AIDS
Hospitalized for Any Reason
Kidney Problems
Mitral Valve Prolapse
Psychiatric Problems
Radiation Treatment
Rheumatic / Scarlet Fever
Severe / Frequent Headaches
Shingles
Sickle Cell Disease / Traits
Sinus Problems
Tuberculosis
Ulcers / Colitis
Veneral Disease
No Medical Concerns
Other
Is the patient allergic to any of the following? (Check all that apply)
*
Aspirin
Any Metals / Plastics
Codeine
Dental Anesthetics
Erythromycin
Latex
Penicillin
Tetracycline
No Allergies
Other
Please list any medications being taken by the patient and reason:
Additional Medical Concerns:
For Women
Are you pregnant?
Yes
No
Emergency Contact Information
Emergency Contact's Name
*
Emergency Contact's relationship to patient:
*
Emergency Contact's Phone Number:
*
Please enter a valid phone number.
Submit
Should be Empty: