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New Patient

New Patient

New Patient Form

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Name*
Select date DD slash MM slash YYYY
Address*
How did you hear about us?*

Dental Insurance Information

Insurance Company #1
Insurance Company #2

Medical History

Are you currently in good health?
Are you currently taking any medications or vitamins (prescription, over-the-counter, recreational)?
Do you currently smoke?
Are you allergic to or ever had a reaction to any of the following:
Are you under the regular care of a physician?
Do you bleed more or longer than normal after a cut, bruise, surgery or previous tooth removal?
Have you ever had a serious illness or operation?
Do you currently have or ever had any of the following conditions?
Women: Are you pregnant?
Is there anything else we should know about your health?

Dental History

Were X-rays taken at your last dental visit?
Have you noticed any signs of the following?
Do you have any clicking, popping or pain in your jaw joint?
Are you aware of clenching or grinding your teeth?
Do you have any missing teeth that you feel should be replaced?
Would you like to improve the appearance of your teeth?
Do you floss your teeth?
Have you had any complications or difficulty with previous dental treatment?
How do you rate yourself as a dental patient?

Confirmation

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