New Patient Form

New Patient Form
Name*

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Gender
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Insurance Information

Billing PriorityCompany
PlanPolicy/Group Number
Insurance/Member ID NumberInsurance Provider Phone
Insured NameInsured Birthdate
Last four digits of SSNPatron's Relation to Insured
Welcome to our practice! What reason(s) are you here today?
Are you currently experiencing dental pain or discomfort?

YesNo
What is the date of your last dental visit with the hygienist? (Estimate if needed)

MonthDayYear
Rate your smile on a scale of 1 to 10, with 10 being completely satisfied:
Have you ever had any of the following in the last 3 years? (Check all that apply)

Bad BreathBad Dental ExperienceBleeding when you brush your teethBleeding when you floss your teethBurning sensation on tongueChew on only one side of the mouthClicking, Popping, or Locking of JawDenture or Partial Denture(s)Difficult ExtractionsDry MouthEar AchesFood Collection Between TeethGrinding/Clenching TeethGums Swollen or TenderHeadachesInjury to your Head, Mouth, or TeethJaw Pain or TirednessLoose TeethMouth BreathingNeck PainOrthodontic Treatment (at any time)Periodontal Therapy (aka Deep Cleaning)Pierced TongueReaction to Dental AnestheticSensitivity to ColdSensitivity to HotSensitivity to SweetsSores or Growths in Mouth
Emergency Contact
Name*

First NameLast Name
Phone Number
Relationship to You

FriendParentSiblingSignificant OtherOther
Women Only (Check all that apply)

PregnantNursingBirth Control PillsHormone Replacement
How many weeks pregnant?
Check all the medical conditions that apply to you:

Abnormal BleedingAIDS/HIVAllergiesAnemiaAnginaArteriosclerosisArthritisArtificial Heart ValueArtificial JointsAsthmaAutoimmune DiseaseBlood Disease/HemophiliaBlood ThinnerBlood TransfusionCancerChest Pain Upon ExertionChronic PainCodeine AllergyCongenital Heart DiseaseCongestive Heart FailureCoumadineDamaged Heart ValueDiabetesDizzinessEating DisorderEmphysemaEpilepsyExcessive BleedingExcessive UrinationFainting SpellsG.E Reflux/Persistent HeartburnGlaucomaGrowthsHay FeverHead InjuriesHearing ImpairedHeart AttackHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney ProblemsLiver DiseaseLow Blood PressureJoint ReplacementMalnutritionMental DisordersMitral Value ProlapsNervous DisordersNight SweatsOsteoporosisPacemakerPersistent Swollen Neck GlandsPrevious Infective EndocarditisRadiation TreatmentRecurrent InfectionsRespiratory ProblemsRheumatic FeverRheumatic Heart DiseaseSeizuresSevere Headaches/MigrainesSevere or Rapid Weight LossSinus ProblemsSleep DisorderSpina BifidaStomach ProblemsStrokeSystemic Lupus ErythematosusThyroid ProblemsTuberculosisTumorsUlcersSTDOther
List the name, specialty, and phone number (if available) of all physician(s) currently caring for you:
Have you had a serious illness, operation, or been hospitalized in the past 5 years?

YesNo
Please provide details here
Has a physician or previous dentist recommended that you take antibiotics prior to dental treatment?

YesNo
Type a question
Are you allergic to or have you had a reaction to: (Check all that apply)

AnimalsAspirinBarbiturateCleocinClindamycinEpinephrineErythromycinFoodIodineLatexLocal AnestheticsMetalsPenicillinSedativeSulfaTetracyclineOther
Have you ever been or are scheduled to be treated with any of these Bisphosphonate drugs? (Check all that apply)

Alendronate (Fosamax)ArediaBonivaRisedronate (Actonel)ZometaOther
List any over the counter and prescription drugs: (Name of Medication, Dosage, Frequency)
List any disease, condition, or problem not listed above that you think we should know about. Also use this space to further explain any condition above.
I certify that I have read and understood the above and that the information given on this form is accurate. I understand the importance of a truthful dental history, and that my dentist and his/her staff will rely on this information when treating me. I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of my errors or omissions that I may have made in the completion of this form.
Signature of Patient or Parent/Legal Guardian

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