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New Patient Form

    Salutation*

    First Name*

    Last Name*

    Date of Birth*

    Registering for a child?*
    YesNo

    Contact Information
    Email*

    Home Phone

    Cell Phone*

    Work Phone

    Address*

    City

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    In case of emergency, please notify:
    Name*

    Relation*

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    Contact Options
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    Whom may we thank for referring you?
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    Referred By

    Are any other members of your family patients at our practice?*
    YesNo

    Insurance Information*
    Yes, insurance applies to meNo, insurance does not apply to me

    Does secondary insurance apply to me?*
    Yes, insurance applies to meNo, insurance does not apply to me

    Medical History

    Are you being treated for any medical condition at the present or any time within the past year?*
    YesNoNot Sure/Maybe

    When was your last medical checkup?*

    Has there been any change in your general health in the past year?*
    YesNoNot Sure/Maybe

    Are you taking any prescription, non-prescription medications, or herbal supplements?*
    YesNoNot Sure/Maybe

    Do you have any allergies?*
    YesNoNot Sure/Maybe

    Have you ever had a peculiar or adverse reaction to any medicines or injections?*
    YesNoNot Sure/Maybe

    Do you have or have you ever had asthma?*
    YesNoNot Sure/Maybe

    Do you have or have you ever had any heart or blood pressure problems?*
    YesNoNot Sure/Maybe

    Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?*
    YesNoNot Sure/Maybe

    Do you have a prosthetic or artificial joint?*
    YesNoNot Sure/Maybe

    Have you ever been advised by a medical professional that you require a prophylactic antibiotic prior to dental treatment?*
    YesNoNot Sure/Maybe

    Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*
    YesNoNot Sure/Maybe

    Have you ever had hepatitis, jaundice, or liver disease?*
    YesNoNot Sure/Maybe

    Do you have a bleeding problem or bleeding disorder?*
    YesNoNot Sure/Maybe

    Have you ever been hospitalized for any illnesses or operations?*
    YesNoNot Sure/Maybe

    Do you have, or have ever had any of the following? Please check*
    Select AllChest pain/anginaOsteoporosis MedicationsMitral Valve ProlapseShortness of BreathRheumatic FeverHeart AttackStrokeCancerPacemakerLung DiseaseHeart MurmurArthritisSteroid TherapyDiabetesTuberculosisDrug/Alcohol DependencySeizuresThyroid DiseaseStomach UlcersKidney DiseaseNone of the above

    Are there any conditions/diseases not listed that you have or have had?*
    YesNoNot Sure/Maybe

    Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?*
    YesNoNot Sure/Maybe

    Do you smoke or chew tobacco products?*
    YesNoNot Sure/Maybe

    Do you consume recreational drugs?*
    YesNoNot Sure/Maybe

    Are you nervous during dental treatment?*
    YesNoNot Sure/Maybe

    For women only: Are you pregnant or breastfeeding?
    YesNoNot Sure/Maybe

    Dental History

    Do you have any specific dental concerns? Please list:

    When was your last dental appointment?*

    How often do you see the dentist?*
    Not ApplicableEvery 3 monthsEvery 4 monthsEvery 6 monthsOnly when something is bothering me

    Is there anything about the appearance of your teeth that you would like to change?

    Have you ever whitened (bleached) your teeth?
    YesNoNot Sure/Maybe

    Do you feel uncomfortable or self-conscious about the appearance of your teeth?
    YesNo

    Have you been disappointed with the appearance of previous dental work?
    YesNo