NEW PATIENT FORM
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Please Select
Single
Married
Widowed
Divorced
Soc. Sec. # of Patient
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
EXT....
Email Address
*
example@example.com
Parent name (if minor patient)
Soc. Sec. #
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact Information
Emergency Contact Information
Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Patient
Primary Dental Insurance
Insured Name
Relationship of Insured Person to Patient
Soc. Sec. # of Insured
DOB of Insured
-
Month
-
Day
Year
Date
Employer
Occupation
Secondary Dental Insurance
Insured Name
Relationship of Insured Person to Patient
Soc. Sec. # of Insured
DOB of Insured
-
Month
-
Day
Year
Date
Employer
Occupation
Referring Dentist
City
General Dentist
City
Physician
City
Date of Last Physical Exam
-
Month
-
Day
Year
Date
Preferred Pharmacy Name & Location
Oral/Dental History
Oral/Dental History
When were your teeth last cleaned?
How long before that?
How often do you brush your teeth?
What times of the day?
Do you use:
Hand Toothbrush
Electric Toothbrush
Are Your Toothbrush Bristles:
Hand Toothbrush
Electric Toothbrush
Do You Use Anything to Clean Between Your Teeth? If Yes, Please List
Are your teeth sensitive? If yes, to what?
Have you ever had braces? If yes, when and for how long?
Have you ever had a deep cleaning?
Gum surgery?
Medical History
Medical History
Are you required to take antibiotics before dental procedures?
Yes
No
Height
Feet
Inches
Weight (lbs)
How is Your General Health?
Good
Fair
Poor
Are You Now Being Treated Or Have You Been Treated Within The Last Year By A Physician?
Yes
No
Surgeries and approximate dates of those surgeries:
Please List Any Prescribed Medications, Over-the-counter Medications Or Herbal Supplements That You Take:
Have You Ever Taken Medication For Bone Density Or Osteoporosis?
Yes
No
If yes, When?
Name of Medication
Have You Ever Had An Allergic Reaction To Any Of The Following?
Aspirin
Yes
No
Codeine
Yes
No
Dental Anesthetics (Novocaine/Lidocaine)
Yes
No
Penicillin
Yes
No
Sleeping Pills
Yes
No
Other Drugs
Have You Ever Tested Positive for HIV?
Yes
No
Heart Trouble
Yes
No
If yes, Explain:
Heart Attack
Yes
No
If yes, Explain:
Heart Murmur
Yes
No
If yes, Explain:
High Blood Pressure
Yes
No
If yes, Explain:
A Stroke
Yes
No
If yes, Explain:
Rheumatic Fever
Yes
No
If yes, Explain:
Cancer
Yes
No
If yes, Explain:
Radiation Treatment
Yes
No
If yes, Explain:
Chemotherapy
Yes
No
If yes, Explain:
Diabetes (Sugar in Blood)
Yes
No
If yes, Explain:
Bleeding Problems
Yes
No
If yes, Explain:
Anemia or Abnormal Blood Counts
Yes
No
If yes, Explain:
Hepatitis (Liver Disease)
Yes
No
If yes, Explain:
Thyroid or Parathyroid Disease
Yes
No
If yes, Explain:
Epilepsy/Convulsions
Yes
No
If yes, Explain:
Lung Disease
Yes
No
If yes, Explain:
Asthma
Yes
No
If yes, Explain:
Tuberculosis
Yes
No
If yes, Explain:
Kidney Disease
Yes
No
If yes, Explain:
Ulcers
Yes
No
If yes, Explain:
Gastrointestinal Disorder
Yes
No
If yes, Explain:
Venereal Disease/STDs
Yes
No
If yes, Explain:
Autoimmune Diseases
Yes
No
If yes, Explain:
Anxiety/Depression
Yes
No
If yes, Explain:
Other Disorders not Listed:
Do you smoke cigarettes?
Yes
No
Do you chew tobacco?
Yes
No
Do you consume any marijuana products?
Yes
No
Does dental work make you nervous?
Do you require or desire sedation for dental work?
Yes
No
For Women Only:
Are you currently taking birth control pills?
Yes
No
Are you pregnant?
Yes
No
If yes, what month?
Are you nursing?
Yes
No
Signature
Should this account become delinquent, I understand that I will be responsible for all reasonable costs of collection.
I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.
Patient Signature
*
Date
*
-
Month
-
Day
Year
Date
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