New Patient Form

FInch Family Dentistry

Medical History Questionnaire
Contact Information
Salutation:

Other
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender

Other
Which one do you prefer to be contacted?

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for the today's Appointment?
When was your last visit to Dentist

MonthDayYear
Date
When was your last Dental X-Ray?

MonthDayYear
Date
What kind of dental work you had in past?
Are you tense/anxiety issue during dental visits?
Insurance details (Primary):

Company

Name of Policy Holder

Group Policy/Plan NumberID/Certificate Number

D.O.B. of Policy Holder
Insurance details (Secondary):

Company

Name of Policy Holder

Group Policy/Plan NumberID/Certificate

D.O.B. of Policy Holder
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Information
Do you have any allergies?
Please give details (Please type N/A if No)
Other Health Care Providers (If Applicable)
Check all the medical conditions that apply to you:

Other
Do you have any of the following allergies?

Other
Surgeries/ Hospitalizations/ Injuries
Current & Recent Medications
For Woman only: (Check all that apply)
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.
Date

MonthDayYear
Date
Signature
Should be Empty:

FInch Family Dentistry

Contact Information

Emergency Contact

Health Information