Patient Forms

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You may need to provide a signature at the office to verify that the information you submitted online is accurate.

Items marked with asterisk (*) must be completed.

First Name

Middle Name

Last Name

prefer to be called Nickname

Street

City

StateProvince

ZipPostal Code

Country

Home Phone

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

CellOther Phone

Format: (000) 000-0000.

Email Address

example@example.com

Birth date MMDDYYYY

Date

Male/Female If patient is a minor, give parent's or guardian's name

Whom may we thank for referring you to our office

Responsible Party

Other family members seen by us

Full Name

Street

City

StateProvince

ZipPostal Code

Country

Mailing Address (if different)

Street

City

StateProvince

ZipPostal Code

Country

Home Phone

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

CellOther Phone

Format: (000) 000-0000.

Email Address

example@example.com

If patient is under 18, please complete this section.

Birth date

Date

Relationship to Patient

Employer

Insureds Name

Insurance Company

Group Number

Local Number

Street

City

StateProvince

ZipPostal Code

Country

Phone Number

Format: (000) 000-0000.

Do you have dual coverage

Insureds Name

Insurance Company

Group Number

Local Number

Street

City

StateProvince

ZipPostal Code

Country

Phone Number

Format: (000) 000-0000.

Name of the nearest relative not living with you

Street

City

StateProvince

ZipPostal Code

Country

Phone

Format: (000) 000-0000.

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Physician

Date of Last Visit

Date

Street

City

StateProvince

ZipPostal Code

Country

Phone

Format: (000) 000-0000.

Please check any of the following which apply to you, and add any relevant comments.

Are you taking any medication

Comment

Are you allergic to any medication

Comment

Do you have a history of any major illness

Comment

Have you had any major operations

Comment

Have you ever been involved in a serious accident

Comment

Please check any of the following that you have had or currently have:

Arthritis

Bone Disorders

Kidney Problems

Pneumonia

RadiationChemotherapy

Are there any medical conditions we have not discussed that you feel we

Are there any medical conditions we have not discussed that you feel we should be aware of

General Dentist

Date of Last Visit

Date

What concerns you most about your teeth?

Please check any of the following which apply to you, and add any relevant comments.

Are you presently in any dental pain

Have you ever experienced any unfavorable reaction to dentistry?

Comment

Have you ever lost or chipped any teeth

Comment

Have there been any injuries to face mouth or teeth

Comment

Is any part of your mouth sensitive to temperature

Comment

Is any part of your mouth sensitive to pressure

Comment

Do you have any type of thumb or tongue habit

Comment

Are you a mouth breather

Comment

Have you ever seen an dentist?

If yes who

When

Do your teeth or jaws ever feel uncomfortable when you awake in the morning

Comment

Are you aware of your jaws clicking or popping

Comment

Are you aware of clenching your teeth during the day

Comment

Have you ever been told that you grind your teeth

Comment

Do you have 'tension' headaches?

Have you ever experienced chronic ringing in your ears?

Comment

By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface. Submit

Submit Your Health History Form Online to Your Dentist

Emergency Information

Medical History