New Patient Form Adult - Fresh Dental

Patient information
Name of Person on the original form

First NameLast Name
Name of Patient

First NameLast Name
Birth Date

MonthDayYear
Marital Status
Select a Choice
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Employer
Spouses Name
Person to Contact in Case of Emergency
University/College Student
How would you prefer your appointment reminders?
Relationship to Patient
Phone Number
Format: (000) 000-0000.
Do you have insurance?
Do you have secondary insurance?
Are you dissatisfied with the appearance of your smile?
Do you have? (please check the following that apply)
If you could change one thing about your smile, what would it be?
What is your primary reason for booking the appointment is today?
Have you had a negative experience, or is there something you would like us to know that will help us make your visit more comfortable?
Patient Medical History
Physician
Physician's Office Phone
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently under any medical treatment?
Have you been admitted to a hospital or needed emergency care during the past two years?
Are you currently taking any medications, including over the counter medications?
Have you ever had any complications following dental treatment?
Are you pregnant?
Do you have any allergies to medications?
Do you have or have had any of the following? Please check all that apply.
Patient Dental History
Check All That Apply
Upload a Photo
We need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive.

Max. file size: 50 MB.
Cancelof
I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that South Airdrie Smiles can electronically file dental claims on my behalf.

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Patient information

Patient Medical History

Patient Dental History

Upload a Photo