Language
  • English (US)
  • Spanish (Latin America)

  • New Patient Registration

    Thank you for choosing Family Dentist of Palm Beach, Inc. for your dental care needs! We promise to do our very best to provide you with the finest care available. To help us meet your entire dental healthcare needs, please fill out this form completely. Call or text us 561-247-5676 if you need any help or have any questions.

  • Patient Information

  • Gender
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  • Whom may we thank for referring you to our practice?

  • Responsible for Payment

    (Someone other than patient providing insurance or payments)

  • Relationship to Patient:
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  • Emergency Contact

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  • Employment Information

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  • Authorization and Release

    I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me, my spouse or my child during the period of such dental care to the third party and/or other health practitioners. 

    I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. 

    I understand that my dental insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. 

     

  • **Payment is required in full before any service is rendered, please have payments in full at each appointment.**

  • Health History 

    Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry that you will be receiving. Please answer all questions and list any and all medications. 

  • Dental History 

  • Reason for your visit:*

  • When was your last dental visit?
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  • How often do you brush your teeth?*

  • What texture brush do you use?*
  • Do your gums bleed while brushing?*
  • Do you feel pain on any of your teeth when brushing or flossing?*
  • Are your teeth sensitive to any of the following?*
  • Have you noticed loosening of your teeth?*
  • Does food tend to get caught between your teeth?*
  • Do you have any sores or lumps in or near your mouth?*
  • Have you ever experienced any of the following problems in your jaw?*
  • Do you have frequent headaches?*
  • Do you clench/grind your teeth while..*
  • Do you bite your lips or cheeks often?*
  • Have you ever had:*

  • Medical History 

  • Are you under a physician's care now?
  • Do you take, or have you taken, Phen-Fen or Redux?*
  • Do you use tobacco?*
  • Would you need to be medicated for any major dental work?
  • Are you pregnant?
  • Are you trying to get pregnant?

  • Commitment to Financial Agreement

  • Release for Use of Images

  • Please answer the questions below if you will be using insurance with your visit.

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  • If you do not have an insurance card please provide the primary insurance holder's information below:

  • Date of Birth
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  • Should be Empty: