New Patient Form

New Patient Form

Martial Status
Gender
MaleFemale
Request Appointment
How did you hear about us?
InternetOutside signMail/flyerOther

DENTAL INSURANCE

Do you have dental insurance:(PLEASE PROVIDE COPY OF INSURANCE CARD)
YesNo

MEDICAL HISTORY

(All information is kept strictly confidential)

Women: Are you pregnant?YesNo
Do you have or have you had any of the following diseases/problems? Specify where required:
AllergiesDizzinessHigh Blood PressureLow Blood PressureStomach ProblemsAnemiaFaintingHead InjuryLiver DiseaseStrokeArthritisEmphysemaHeart DiseaseMultiple SclerosisThyroid DiseaseArtificial JointsEpilepsyHeart MurmurRadiationTMJAsthmaGastro IntestinalHepatitis A, B, CRespiratory ProblemsTumorsBlood DiseaseGlaucomaHIV (AIDS)RheumatismUlcersCancerHard to FreezeHivesSinus ProblemsSTDDiabetesHay FeverKidney DiseaseAnything Not Listed?

DENTAL HISTORY

Are your teeth sensitive to cold, heat, sweets etc.?

YesNo

Do you have bad breath / bad taste in your mouth?

YesNo

Do your gums bleed when brushing, flossing?

YesNo

Do your gums feel tender or swollen?

YesNo

Do your jaws crack, pop or grate when you open widely?

YesNo

Do you grind or clench your teeth?

YesNo

Do you have food catch between your teeth?

YesNo

Are you satisfied with your teeth? Rate your smile on a scale from 1 (min) -10 (max).

GENERAL RELEASE

This is to certify that I the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated and I will assume responsibility for fees associated with those procedures for myself and my dependents. I consent to the collection, use, retention and disclosure of personal information including photos for my chart as required for dental care. I authorize the release of my personal information regarding my diagnosis and treatment to my dental insurance for claims submitted electronically or manually. This authorization shall continue in effect until the undersigned revokes it.

Existing Patient Form

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