• New Patient Form

  • Date of Birth*
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  • Today’s date*
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  • Are you being treated by a medical doctor now?*
  • Have you ever been hospitalized or treated for a serious illness or injury?*
  • Do you bleed easily or do cuts in your skin stay open a long time?*
  • Have you ever fainted?*
  • Do you have any pains in the chest?*
  • Do you have or are you a carrier of an infectious disease?*
  • Are you allergic (i.e. itching, swelling of hands, feet, or eyes) or made sick by any medicines? Penicillin or other antibiotics, Local anesthetics (freezing), Aspirin, Codeine, Sulfa,*
  • Are you being treated for osteoporosis?*
  • Are you taking any medicine or pills of any kind, including oral contraceptives, and herbal medicine?*
  • Do you have or ever had any of the following (please Check)
  • Are you pregnant?*
  • When is the due date?
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  • Are you presently in good health?*
  • Is there anything else about your health that we should know about?*
  • Are you experiencing any of the following? (please Check)
  • Are your teeth sensitive to
  • Have you had any problems with previous dental treatment?*
  • What was done?
  • Have you ever had any injury, surgery or x-ray therapy to the face, head, neck, mouth or jaws?*
  • Do you smoke or chew tobacco?*
  • Do you brush your teeth*
  • Do you floss your teeth*
  • Are you concerned about the appearance of your teeth or your smile?*
  • I am concerned about
    • To the best of my knowledge, all the preceding answers are true and correct.
    • If I ever have any change in my health, or if my medicine changes, I will inform the dental staff at the next appointment.
    • I consent to whatever dental procedures, anesthetics, and/or x-rays that are necessary for the treatment of my case.
    • I will assume responsibility for fees associated with those procedures. Fee payment is due at the time of service unless other prior arrangements have been made with Dr. Palka Sawhney Sharma.
    • I have read the “Dental Office Personal Information Consent Form” and do consent to the collection, use, and disclosure of my personal information for the purpose of optimizing my health care

  • Confidential Personal Information

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  • Date Of Birth*
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  • How did you hear about our office? (Please check one)

  • Dental Insurance Information

  • Providing us with the following information will allow us to help you with dental insurance claim submissions. Many insurance companies today accept claims electronically, resulting in a more time-efficient reimbursement process. We are equipped to handle these electronic submissions for you. If your insurance company does not yet accept electronic claims, we will gladly mail these on your behalf.

  • Date of Birth
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  • Benefit Period
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  • Do you have secondary Insurance
  • Date of Birth
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  • Benefit Period
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  • Date*
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  • Should be Empty: