NEW PATIENT FORM
Please fill out all the details accurately
Patient Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of Birth (eg. Jan 12 2023)
Reason for Visit
*
Adult Patient: Full Mouth Check up (Recommended for all new patients)
Adult Patient: Single tooth or Emergency Check up
Kids: Full Mouth Check up (Recommended for all new patients)
Kids: Single tooth or Emergency Check up
Please summarize your Chief Complaint briefly.
eg. Pain/Sensitivity on Upper Right Side since 5 days.
Back
Next
Dental History
Please fill out these questions to the best of your knowledge.
How often do you brush?
*
Please Select
Once a day
Twice a day
Every other day
Do you use a Fluoridated Toothpaste?
*
Please Select
Yes, I use a fluoride toothpaste
No, I do not use a fluoride toothpaste
I don't know what a fluoride toothpaste is
Do you use a manual or electric toothbrush?
*
Please Select
Manual
Electric
Do your gums bleed while brushing or flossing?
*
Please Select
Yes, they bleed a lot
Yes, only sometimes
No, they rarely bleed
Do you have any teeth that are sensitive to hot, cold or while biting?
*
Please Select
Yes
No
Do you clench or grind your teeth?
*
Please Select
Yes
No
How would you rate the health of your mouth?
*
Please Select
Excellent
Fair
Poor
Are you concerned about the appearance of your teeth?
*
Please Select
I don't like my smile, but I'm fine with the way it is
I don't like my smile and would like to know what options I have to improve it
I am okay with my smile, perhaps they can be more straighter/whiter/symmetrical
I have a perfect smile and I should be featured on your clinic's social media page
Please Tick if you have any/one of the following medical conditions
*
Hypertension (Average BP of 130/80 or more)
Diabetes
Allergies to antibiotics, pain medications or any other
History of Cancer
History of any joint replacements in the last 5 years
Blood disorders
Any other dental related medical issues
NONE OF THE ABOVE
Other
If you are a female patient, are you currently pregnant?
*
Please Select
Yes
No
How fearful are you to visit the dentist?
*
Please Select
Very fearful
Apprehensive
Neutral
Calm and relaxed
Would you be interested in saving 10% off your next preventive visit by providing us with a google review and/or testimonial after this visit?
*
Yes, I'll provide a review at the end of today's visit
Not Interested
Please sign here to certify that all the information you've provided is accurate.
*
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