It isn't necessary to stay longer at our office, filling out the new patient forms. You can complete them online! Simply enter your information in the embedded form below and submit securely right here from this page. (Please note that there are four forms and we request that you complete each one.) If you have any questions, just call us and we will be more than happy to provide answers or clarification.
Name *
Preferred Name
Birthdate *
SSN
Sex *
Email Address *
Phone Number *
Alt. Phone Number
Address *
Select a state / province
Marital Status *
Single
Married
Spouse Name
Spouse Birthdate
Spouse SSN
Spouse Occupation
Spouse Phone Number
Spouse Employer
Full Time
Part Time
Self Employed
Student
Retired
Home Maker
Unemployed
Employer
Employer Phone Number
If the patient is not a minor, please disregard this section
Who does the patient live with?
Guardian 1
Guardian 2
Guardian 1 and 2
Other
Guardian 1 Name
Guardian 1 Relationship to Patient
Guardian 1 Birthdate
Guardian 1 SSN
Guardian 1 Sex Select Male Female Other
Guardian 1 Email Address
Guardian 1 Phone Number
Guardian 1 Alt. Phone Number
Guardian 1 Address
Select a state / province State 1 State 2 State 3
Guardian 1 Employer
Guardian 1 Employer Phone Number
Guardian 1 Relationship to Guardian 2
Separated
Divorced
Guardian 2 Name
Guardian 2 Relationship to Patient
Guardian 2 Birthdate
Guardian 2 SSN
Guardian 2 Sex Select Male Female Other
Guardian 2 Email Address
Guardian 2 Phone Number
Guardian 2 Alt. Phone Number
Guardian 2 Address
Guardian 2 Employer
Guardian 2 Employer Phone Number
Responsible Party is
Same as Guardian 1
Same as Guardian 2
If the patient is the responsible party, please disregard this section
Relationship to Patient
First Name
Last Name
Birthdate
Sex Select Male Female Other
Email Address
Address
City
State / Province Select a state / province
Zip / Postal Code
Phone Number
Emergency Contact Name *
Relationship to Patient *
Alt. Phone Number *
Please share with us how you heard about our office. Thank you. *
Google
Facebook
Family Member
Pediatrician/Physician
Insurance
Website
Yelp
Friend
Dentist/Dental Office
Community Event
Media Ad (radio, movie theater, etc.)
Print Ad (magazine, newspaper, etc.)
School/Daycare
Signature *
Use your mouse or finger to draw your signature above
Clear Next
Privacy Policy
Date of Last Health Care Exam:
What was this exam for?
When was your last dental exam?
Are you currently being treated by a physician for a specific condition?
Yes
No
Have you recently been hospitalized or had a major operation?
Have you ever had a joint replacement?
Did your orthopedic surgeon recommend antibiotics before dental treatment?
Please list all the names and phone numbers of the physicians who are currently providing you care:
Pre-medication before dental treatment
Antacids
St. John's Wort or Kava-Kava
Dilantin® or Tegretol®
Biaxin® (Clarithromycin)
Cardizem® (Diltiazem) or Calan, Isoptin® (Verapamil)
Barbiturates (any)
Diflucan® (Fluconazole) or Sporanox® (Itraconazole)
Have you been treated with Bisphosphonate drugs (Fosamax®, Aredia®, Zometa®, Actonel®, Boniva®, RECLAST®) or PROLIA®?
If so, when did the treatment begin?
When did the treatment end?
Do you consume grapefruit juice, grapefruits or grapefruit extract?
Have you traveled outside of the US recently?
If yes, where?
Have you been in contact with anyone exposed, suspected to have been exposed, or has been diagnosed with Coronavirus/COVID-19? *
Have you recently experienced a fever, cough, or difficulty breathing?
Please list any medications you are currently taking and dosages:
Please list any dietary or herbal supplements you are taking, and for what purpose:
Do you use recreational drugs?
If so, which ones?
Do you suspect or have you been told that you snore?
Do you suspect or have you been diagnosed with sleep apnea?
Are you being treated for sleep apnea with a CPAP, BiPAP, or other device?
Women (Please check all that apply)
Pregnant
Currently nursing
None of the above
Trying to get pregnant
Taking oral contraceptives
ABNORMAL BLOOD PRESSURE?
Have you ever received a diagnosis of "high blood pressure" or "low blood pressure"?
What is your normal blood pressure?
What is your blood pressure today?
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic) *
Aspirin
Iodine
Latex
Metal
Penicillin
Valium
Acrylic
Local Anesthetics
Novocaine
Sulfa Drugs
Xylocaine
Erythromycin
Nitrous Oxide
Tetracycline
None of the Above
If other, please list
Additional adverse reaction or allergies not listed above?
Epinephrine
Antibiotics other than Penicillin
Ibuprofen or Tylenol®
Codeine, Valium®, Hydrocodone, Oxycodone or other sedatives
Metals
TOBACCO, ALCOHOL, DRUGS
Do you use tobacco?
If yes:
Smoke
Chew
Do you consume alcohol?
If yes, approximately how many alcoholic beverages per week?
Do you use any mood-altering drugs other than those previously listed?
WEIGHT AND DIET CONSIDERATIONS
Weight
Height
Meals Per Day
Dietary Restrictions
Food Allergies
Sugar in your diet (Choose One)
None
Slight
Moderate
High
Do you have, or have you ever had any of the following medical conditions? (Please select all that apply)
Anemia
Cortisone Medication
Frequent Headaches
High Blood Pressure
Liver Disease
Rheumatism
Stroke
Heart Attack/Heart Failure
Congenital Heart Problems
Emphysema
Heart Valve or Pacemaker
Lung Disease
Ulcers or GI Problems
Convulsions
Frequent Diarrhea
Hepatitis (B or C)
Leukemia
Renal Disease
Stomach/Intestinal Disease
Yellow Jaundice
Cancer
Eating Disorder
Heart Trouble
Jaw Joint Pain
Tumor or Growth
Chemotherapy
Excessive Bleeding
Hay Fever
Hives or Rash
Parathyroid Disease
Shingles
Thyroid Disease
Blood Disease
Diabetes
Frequent Urination
Herpes
Rheumatic Fever
Asthma
Easily Winded
Genital Herpes
Low Blood Pressure
Mitral Valve Prolapse
Scarlet Fever
Swelling of Limbs
Artificial Joint
Currently Pregnant
Epilepsy or Seizures
Hepatitis (A)
Psychiatric Care
X-ray/Chemotherapy
Cold Sores/Fever Blisters
Frequent Cough
Hemophilia
Kidney Problems
Recent Weight Loss
Spina Bifida
Venereal Disease
Bruising Easily
Drug/Alcohol Addiction
Heart Murmur
Hypoglycemia
Tuberculosis
Chest Pains
Comments on patient interview concerning medical history:
Significant findings from questionnaire or oral interview:
Dental management considerations:
Date
Doctor Signature
Clear
I understand the above information is necessary to provide me with 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 and medication.
Date *
Clear Use your mouse or finger to draw your signature above
Next
How do you feel about dental treatment?
Relaxed
A little uneasy
Tense
Anxious
Very Anxious
Have you seen a dentist before?
If so, when was your last dental visit? Within the last 3 months 3-6 months ago 6-12 months ago More than 12 months ago
How would you rate your previous dental experience? Excellent Good Fair Poor
What are your dental concerns?
Have you avoided regular dental care?
If so, why have you avoided regular dental care?
Are you happy with the appearance of your teeth?
If not, why are you unhappy with the appearance of your teeth?
How often do you brush? Less than once per week 1-2 times per week 3-4 times per week Daily More than once per day
How often do you floss? Less than once per week 1-2 times per week 3-4 times per week Daily More than once per day
How often do you use other aids? Less than once per week 1-2 times per week 3-4 times per week Daily More than once per day water flosser, gum picks, gum stimulator, etc.
Would you like your teeth to be whiter?
Would you like your teeth to be straighter?
Do you have, or have you ever had any of the following dental conditions? Please check all that apply. *
Aching or sensitive teeth
Areas of food traps
Broken fillings
Cavities
Cold sores
Dry mouth
Facial surgery
Growths or lesions in your mouth
Gum treatments
Jaw clenching
Night grinding
Orthodontic treatment
Swelling or lumps in the mouth
Active decay of teeth or gums
Bad breath
Bleeding gums
Broken or missing teeth
Clicking or popping jaw
Difficulty chewing
Excessive anesthetics with teeth
Facial pain
Gum infection / disease
Jaw pain
Lip or cheek biting
Oral surgery
Sore jaw muscles
Sensitive or bleeding gums
Swollen glands
Unfavorable dental experience
Name of previous dentist or dental office
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status.
By providing a mobile number, I agree that the practice may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.
Will you be using insurance? *
If you're not using insurance, please disregard this section
Insured's Name
Insured's Employer
Insured's Birthdate
Insured's SSN
Insurance Company
Insurance Phone Number
Policy Number
Group Number
Address 1
If you do not have dual insurance coverage, please disregard this section
Δ
