• General Patient Information

  • Marital Status*
  • Preferred method of contact*
  • This contact is for*
  • How did you hear about us?

  • Medical History

  •  -
  • Do you have any drug allergies?*
  • Have you ever had (Please check all that apply)*
  • Are you currently taking any medications?*
  • Have you ever had any complications following a medical or dental procedure? If so please explain:*
  • Have you been admitted to the hospital or needed emergency care during the past two years?*
  • Are you now under the care of a physician for any specific health concerns?*
  • Is there anything else you think we should know regarding your medical history?*
  • Informed Consent*

  • Dental History

  • Please check any of the following that apply to you:*
  • If you could change your smile you would:*
  • Please circle any of the services below you would like our staff to discuss with you during your visit:*
    • Family Member 1 
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Have you ever had (Please check all that apply)*
    • Family Member 2 
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Have you ever had (Please check all that apply)*
    • Family Member 3 
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Have you ever had (Please check all that apply)*
    • Family Member 4 
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Have you ever had (Please check all that apply)*

  • Dental Insurance

    Apple Tree Dentistry accepts all insurance plans. If your policy permits, payment will be billed directly to your insurance company. For patients with a copay, the estimated out-of-pocket cost will be provided before your appointment begins, and collected day of treatment.
  • Will you be utilizing dental insurance for your visits?*
    • If yes, please fill out the following as it applies to you 
    • Primary Plan
    • Secondary Plan (if applicable)
    • Informed Consent

  • Transferring Radiographs

  • If yourself or any family members have had x-rays taken within the past two years, and would like to have them transferred to our office, please sign the x-ray release below.

    We will also get the dates of your last check-up and cleaning to ensure we stay within the confines of your insurance policy. 

  • Would you like us to contact your previous office?
    • Please fill out the following 
    • Additional Family Members

    • I authorize the transfer of radiographs taken in the past two years for myself and above mentioned family members to Apple Tree Dentistry.  Please include dates of last recare, complete exam, bitewings, panoramic x-ray and scale. 

       

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