• New Patient Medical History Form

    Thank you for choosing iSmile Family Dentistry. Please complete the following form prior to your upcoming appointment. You may contact our office with any questions.

  • NEW PATIENT INFORMATION

  • Marital Status:
  • Birth Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE/FINANCIAL INFORMATION

    Please give your insurance card to the receptionist upon arrival.
  • Is the patient also the person responsible for the bill?*
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Is the address the same as the patient address?
  • Is this person a patient here?
  • Patient's Relationship to Subscriber:*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • IN CASE OF EMERGENCY

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dr. Singh to release any information required to process my claims.

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • MEDICAL HISTORY

  • Are you in good health?
  • Format: (000) 000-0000.
  • Date Of Last Physical Exam:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please list all medications (prescription and over the counter), vitamins and diet/herbal supplements you are taking. You may also upload a list of your medications below instead of listing them out.

  • Rows
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Please answer "Yes" if you have the following conditions:

  • Rows
  • Rows
  • Rows

  • An omittance to the above conditions does not make iSmile Family Dentistry liable for a health condition not being communicated prior to treatment. If you have a health condition not listed above, please list it below:

  • WOMEN ONLY:

  • Are you nursing?
  • Are you taking birth control or hormonal replacement?

  • ALLERGIES:

  • Please list all allergies:

  • JOINT REPLACEMENT:

  • Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? If yes, list date of surgery.

  • I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries 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 errors or omissions that I may have made in the completion of this form.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dental History

  • Please answer "Yes" if you have the following conditions:
    Rows
  • Date of your last dental exam:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last X-rays?
     - -
    2 digit month, 2 digit day, 4 digit year

  • Office Policy

    Please kindly give us a minimum of 48 hours notice to cancel your appointment or there will be a $70 Cancellation/No Show Fee

  • Should be Empty: