New Patient Paperwork

New Patient Paperwork

Adult (18+) Form
Thank you so much for filling out your new patient paperwork prior to your appointment. This gives the doctors a chance to review everything ahead of time and expedite your first visit with us. We look forward to meeting you, and please don't hesitate to give the office a call if you need any assistance (818) 532-2977.

- The Garfinkle Family Dental Team
Basic Information
Full Name

First NameLast Name
Preferred Name
[If different than your legal name]
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Gender

MaleFemale
Marital Status
Home Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Email Address
[For appointment reminders only]
Occupation
Whom/What can we thank for referring you?*
In Case of Emergency Contact
Full Name and Relationship
Phone Number

Area CodePhone Number
Dental Insurance Information
Will we be assisting you with filing dental insurance?

YesNo (please skip to dental health history)
Insurance Company Name
[including state if applicable]
Subscriber's Full Name
Subscriber's ID Number (#)
Subscriber's Date of Birth

MonthDayYear
Dental Health History
By checking the boxes below, you indicate a "YES" response and leaving it blank indicates a "NO" response.
Had problems w/previous dental treatment?Do you gag easily?Do you wear partial/complete dentures?Does food catch between your teeth?Do you have difficulty chewing?Do you chew on only one side of your mouth?Do you avoid brushing any particular area?Do your gums bleed easily?Do your gums bleed when you floss?Do your gums feel swollen or tender?Have you ever noticed slow-healing sores?Would you like whiter teeth?Are you dissatisfied w/your smile’s appearance?Do you brush at least twice a day?Do you floss at least once a day?Does your jaw ever make noise?Do you clench/grind your teeth frequently?Do your jaws ever feel tired?Does your jaw ever get “stuck”?Do you get earaches/pain in front of the ears?Do you find jaw pain frustrating/depressing?Do you have TMD (Temporomandibular Jaw Disorder)?Do you have pain the face, cheeks or temples?Are you aware of an uncomfortable bite?Have you ever had trauma to your jaw?Do you frequently chew gum or smoke a pipe?
Are your teeth sensitive to:

Hot foods or liquids?Cold foods or liquids?Sours?Sweets?
Which of these is the most worrisome to you?
Medical Health History
Please note you will be asked each visit if there has been any changes or additions to this medical history, and it is imperative you let us know if anything changes so we can continue to provide you the most comprehensive dental care.
By checking the boxes below, you indicate a "YES" response and leaving it blank indicates a "NO" response.
Do you have, or have you ever had any of the following?

AnemiaArthritisArtificial JointsAsthmaBlood DiseaseBone/Joint ProblemsCancerDiabetesDizzinessEasily BruiseEpilepsyExcessive BleedingFaintingGlaucomaHeadaches (Frequent/Severe)Head InjuryHeart DiseaseHeart MurmurHepatitis (A, B or C)High Blood PressureHistory of Tobacco UseHistory of Drug/Alcohol AbuseHIV (Human Immunodeficiency Virus)HPV (Human Papillomavirus)JaundiceKidney DiseaseLiver DiseaseMental Disorder(s)Nervous DisordersPacemakerRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSeizuresSinus ProblemsStomach ProblemsStrokeThyroid ProblemsTuberculosisTumorsUlcersVenereal Disease
WOMEN ONLY

Are you pregnant, trying to conceive or nursing?Are you taking any form of contraceptive?Have you reached menopause?
Are you required by a physician to medicate with antibiotics prior to dental appointments?

YesNo
Please list any allergies:

NonePenicillin, Amoxicillin or other antibioticsAspirin, Acetaminophen or IbuprofenCodeine, Demerol or other narcoticsLatex or other rubber(s)Local Anesthetics (“Novocaine”)Reaction to MetalsOther
Please list any/all current medications (including herbal):
Primary Care Physician (if applicable):
Full Name
Phone Number

Area CodePhone Number
By selecting "Submit Paperwork" below, your information will securely and safely forwarded to our office. Upon your arrival, you will be asked to sign a copy of our Office Policies and our Acknowledgement of HIPAA Privacy Practices. Again, we look forward to meeting you!
Should be Empty:

New Patient Paperwork

Basic Information

Dental Insurance Information

Dental Health History

Medical Health History