New Patient Form

 
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    Patient Information

    Today's Date:

    Your Name (required)

    Your Address* (required)

    Address 2nd

    City* (required)

    State* (required)

    Zipcode* (required)

    Email: (required)

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

    Employed by:

    Occupation:

    Employer Address:

    Address 2nd:

    City

    State

    Zipcode

    Business Phone:

    Spouse's Name:

    Employed by:

    Occupation:

    Employer Address:

    Address 2nd:

    City

    State

    Zipcode

    Business Phone:

    Referred By:

    Method of Payment

    CashCheckCredit CardDiscVisaMaster Card

    Social Security #:

    Spouse's Social Security #:

    Driven License #:

    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!