• New Patient Registration

    New Patient Registration

  • YOUR PERSONAL CONTACT INFORMATION

  • Gender you identify as*
  • Date of Birth:*
     - -
  • Format: (000) 000-0000.
  • *
  • Format: (000) 000-0000.

  • HOW DID YOU FIND US

  • Found Us Online? Where did you first hear about us?*

  • EMERGENCY CONTACT INFORMATION

  • Format: (000) 000-0000.

  • MEDICAL CONTACT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • I provide consent to Nobleton Dental Smiles to contact my medical physician for any medical information required to provide the care they require.*

  • MEDICAL INFORMATION

    The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality
  • Your Last Medical Visit/Appointment:*
     - -
  • Your Last Medical Appointment for a Comprehensive Physical:*
     - -
  • Are you being treated for any medical condition:*
  • Your medical state has undergone any changes in the past year?*
  • Do you have any allergies to medications, latex, foods, or other?*
  • Do you have or have had heart issues:*
  • Do you have any prosthetic or artificial joints?
  • Do you have any immune system conditions?*
  • Have you been hospitalized for any illness or operations?*
  • Do you smoke, vape, use e-cigarettes, or chew tobacco products?*
  • Do you have any disabilities we should be aware of*

  • If Applicable to your gender:

  • Are you pregnant?*
  • Breastfeeding:*

  • MEDICAL REVIEW

  • Do you have any of the following conditions:*

  • DENTAL INFORMATION

  • Your Last Dental Cleaning:*
     - -
  • Your Last Dental Examination:
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  • Did you visit your last dental office as suggested your dentist or hygienist?*
  • Frequency of Dentist/Hygienist visit:*
  • What emotions you experience with dentistry?*
  • I Schedule my Dental Appointments based on the*
  • Do you like your Smile? Can we do a complimentary smile assessment?*
  • Have you whitened your teeth before?*
  • Do you Snore?*
  • Do you grind your teeth?*
  • Do you suffer from migraines or any TMJ symptoms?*
  • Have you done Orthodontics?*
  • If yes, When?
     - -
  • Have you had any dental experiences that caused you to fear or dislike dentistry?*

  • FINANCIAL AGREEMENT

  • We accept the following methods of payment at our dental practice: Visa, Mastercard, Debit, Dental Insurance.

    We can directly bill to your dental plan if your dental plan accepts this and agrees to direct billing. Each dental plan provided is unique to the financial decision and agreement between an employer/individual seeking coverage and the insurance carrier. Our dental fees arebased on the current year dental fee guide. Please indicate which is best for you:

  • DENTAL INSURANCE INFORMATION

  • Primary Dental Plan

  • Date of birth of Primary Plan Holder:
     - -

  • Secondary Dental Plan

  • Date of birth of Primary Plan Holder:
     - -

  • APPOINTMENT AGREEMENT

  • We will provide a courtesy call and email to confirm all dental appointments. We would like a mutual agreement if the time you selected for a dental appointment does not work for your schedule you provide 3 business days notification by email and a call to our office. If we are unable to reach you 1 day prior to your dental appointment after attempting to call and email multiple times, we will cancel this appointment until we are able to communicate with you directly. We understand emergencies happen and this is understandable and documented on our patient records. Our team will request a deposit after a history of continuous short notice cancellations and missed appointments to schedule dental visits at our office.

  • Today’s Date:*
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  • Should be Empty: