• NEW PATIENT FORM

    PLEASE COMPLETE THE FOLLOWING INFORMATION.
  • DATE
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • GENDER
  • MARITAL STATUS:

  • ACCOUNT INFORMATION

  • Format: (000) 000-0000.

  • GETTING TO KNOW YOU

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

  • DENTAL INSURANCE

  • RELATIONSHIP TO PATIENT:

  • SECONDARY CARRIER

  • RELATIONSHIP TO PATIENT:

  • CONSENT FOR TREATMENT

  • I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient) {patientName}’s dental needs.

    Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

    I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

    I give consent to the doctor’s or designated staff’s use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

    I agree to be respnsable for payment of all services rendered on my behalf or my dependants. I understand that payment is due at the time of service unless other arrangements have been made.

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

  • MEDICAL HISTORY

    Please take a moment to let us know about your medical & dental history so we may provide you with the best possible care. All information is confidential.
  • Format: (000) 000-0000.
  • 1. Have you had any medical care within the past two years?
  • 2. Have you taken any medication or drugs during the past two years?
  • 3. Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosage of aspirin?
  • 4. Have you ever taken prescription medications for weight loss (diet pills)?
  • If yes, did you take any of the following? CHECK ALL THAT APPLIES:
  • If yes to any of the following above did you have a medical exam for heart issues?
  • 5. Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs?
  • 6. Are you aware of having an allergic ( or adverse) reaction to any substance or medication
  • 7. Have you been a patient in the hospital during the past five years?
  • 8. Indicate which of the following you have had, or have present. Check “Yes” or “No” to each item.*
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  • 9. Have you lost or gained more than 10 pounds in the past year?
  • 10. Do you have or have you had any disease, condition, or problem not listed?
  • 11. Women: Are you pregnant or think you may be pregnant?
  • Are you nursing?
  • 12. Do you use birth control prescriptions?

  • I understand the above information is necessary to provide me wth dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

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

  • DENTAL HISTORY

  • Have you ever used or are currently using a topical fluoride or rinse?
  • Do you have any dental problems now?
  • ARE ANY OF YOUR TEETH SENSITIVE TO:
    Rows
  • HAVE YOU EVER HAD
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  • DO YOU
    Rows
  • HAVE YOU EVER EXPERIENCED
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  • Are you satisfied with you teeth’s appearance?
  • Would you like to keep your teeth all your life?
  • Do you feel nervous about your dental treatment?
  • Have you ever had an upsetting dental experience?
  • Have you ever been told to take a pre-medication prior to dental treatment?
  • Should be Empty: