New Patient Form

 

Patient Information

Today's Date:

Your Name (required)

Your Address* (required)

Address 2nd

Email: (required)

Sex: (required)
MF
Marital Status: (required)
SingleMarriedDivorcedWidowed

Employed by:

Occupation:

Employer Address:

Address 2nd:

Business Phone:

Spouse's Name:

Employed by:

Occupation:

Employer Address:

Address 2nd:

Business Phone:

Referred By:

Method of Payment

CashCheckCredit CardDiscVisaMaster Card

Do You Have Dental Insurance?

YesNo

Insurance Company:

Medical History

Do You or Have You Ever Had Any of The Following? (Please check Yes or No)

Hiatal Hernia or Stomach Trouble
YesNo

Rheumatic Fever
YesNo

Heart Disease
YesNo

Angina (Chest Pain)
YesNo

High or Low Blood Pressure
YesNo

Stroke
YesNo

Kidney Trouble
YesNo

Arthritis or Emphysema
YesNo

Productive Cough or Recent Cold
YesNo

Hay Fever, Allergies, or Hives
YesNo

Liver Disease, Yellow Jaundice, Hepatitis
YesNo

Thyroid Disorder
YesNo

Epilepsy, Seizures, Convulsion
YesNo

Difficulties in Hearing or Eye Disease
YesNo

Psychiatric or Nervous Disorder
YesNo

Are You Taking Birth Control Pills?
YesNo

Are You Pregnant?
YesNo

Alcohol? If so, how much
YesNo

Do You Smoke? If so, how much
YesNo

Complication Following Childhood Disease
YesNo

Frequent Fainting
YesNo

Sinus Trouble
YesNo

Poor Experience with Dentistry
YesNo

Excessive or Prolonged Bleeding
YesNo

Anemia Blood Disorder
YesNo

Sickle Cell Disease Trait
YesNo

Severe Headache
YesNo

Adverse Effects or Reaction to:

Local Anesthetics (Novocaine etc)
YesNo

Penicillin
YesNo

Any Other Drugs
YesNo

Any of the Following Heart Conditions:

Prosthetic Valve
YesNo

Mitrial Valve Prolapse
YesNo

Enlarged Heart
YesNo

Endocarditis
YesNo

Congenital Cardiac Defects
YesNo

Cardiac Surgery of Any Kind
YesNo

Valvular Dysfunction
YesNo

Heart Murmur
YesNo

Do you take aspirin?
YesNo

List Any Other Serious Illinesses:

Have You Been Hospitalized Withing The Last 2 Years?:

YesNo

Why?

Please List Medications You Have Allergies to:

Are You Now or Have You Recently Been Under The Care of a Physician?

YesNo

Why

Are You Taking Any Medication Prescribed or Self-Administered?

YesNo

What

Have You Ever Had Radiation Treatments?

YesNo

Extent:

When?

Please Describe Any Other Medical Condition You Feel We Should Be Aware of:

I, the undersigned, certify that all of the above medical and dental information is true to my knowledge. I have not omitted any pertinent information.

I, the undersigned, will assure responsibility for fees associated with these procedures. Insurance coverage is an agreement between you, the patient and your insurance company. As a courtesy, we can work with your insurance company with a pre-determination in writing from them the ultimate responsibility for payment lies with you the patient.

*We need to obtain a copy of your Driver's License, Social Security Cards, and Insurance Card if Insured. Please Have Then available. Thank you!