New Patient Form

New Patient Form - General Information

(PAGE 1 OF 8)
Today's date:*

MonthDayYear
Date
Name*

PrefixFirst NameMiddle NameLast Name
Pronounciation
I prefer to be called
Gender*

MaleFemale
Birthdate*

MonthDayYear
Date
Residence Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residence Phone Number
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Employer
Occupation
Work Phone Number
Please enter a valid phone number.
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
Name of Spouse

First NameMiddle NameLast Name
Spouse's Employer
Spouse's Occupation
Spouse's Employer Phone Number
Please enter a valid phone number.
Spouse's Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is legally responsible, if other than patient?

First NameMiddle NameLast Name
Relationship to patient
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By whom were you referred?
Do you have dental insurance?*

YesNo

Permission for Use of Photographs

(PAGE 8 OF 8)
All patient care in this office includes clinical photographs of your mouth that aid us during the entire process of your care from diagnosis to treatment planning to definitive restorative care. The information gleaned from these photographs is invaluable for your doctor, any referring specialists and our on-site world-class team of dental technologists.

Drs Sheets, Paquette, and Wu in addition to their full time practice of Prosthodontics, lecture internationally to dentists to share with them the latest in dental materials, techniques and approaches to restoring oral health and esthetics to their patients. Sharing case histories as a part of that educational experience is critical to the learning process. Please let us know if you will allow us to use your treatment photographs, if deemed instructional, for dental continuing education. Of course, it is impossible for anyone to identify a patient by these photographs and the gift of your information will remain anonymous, as no names will be used in these presentations.

If you feel that you would like to be a part of instructing other dental professionals with the use of your facial photos as well as the clinical photographs, please let us know by signing the statement at the end of this persmission slip acknowledging that desire.

Warm regards and appreciation for your thoughtful consideration of this request.

Sincerely,
Cherilyn G. Sheets, DDS
Jacinthe M. Paquette, DDS
Jean C. Wu, DDS
If my treatment provides information that will be used to instruct other dental professionals in techniques that will help other patients, I approve the use of clinical photographs. I further understand that my name will not be used in these presentations.
Signature

Clear
In addition, if my case provides information that will instruct other dental professionals in techniques that will help other patients, I approve the use of facial photos.
Signature

Clear
Should be Empty:

	Name	Purpose	Frequency	Since
Heart medication
Blood pressure medication
Nitroglycerine
Blood thinners
Inderal
Antibiotics
Sedatives
Tranquilizers
Pain Medication
Cortisone (Steroids)
Thyroid
Birth Control Pills
Bisphophonates (Bone Building Drugs)
Steroids

New Patient Form - General Information

Medical History

Medical History

Medical History

Dental History

Dental History

Sleep Health Questionnaire

Section 1 - Patient Sleepiness Scale

Section 2 - Signs & Symptoms

Section 3 - Sleep History

Permission for Use of Photographs