New Patient Form

New Patient
Address
Gender

If this appointment is for your child, please complete the following:

Guardian Address (If different than the patient address)
Gender

Dental Insurance

Primary Carrier

Second Carrier

Getting to know you

Health History

1. Are you feeling pain or discomfort at this time?
2. Have you had a medical examination in the last year?
3. Do you feel very anxious about having dental treatment?
4. Have you been a patient in the hospital during the past two years?
7. Are you allergic or have you reacted adversely to any of the following medications?
8. Are you aware of being allergic to any other medications or substance?
9. Circle any of the following which you have had or have at present:
10. Do you wish to speak privately to the Doctor about any medical condition?
11. When walking up stairs or taking a walk, do you ever stop because of pain in your chest?
12. Do your ankles swell during the day?
13. Have you lost or gained more than 10 pounds in the past year?
14. Do you ever wake up from sleep short of breath?
15. Are you on a special diet?
16. Has your medical doctor ever said you have a cancer or tumor?
17. Do you have a tendency to faint?
18. Do you have frequent severe headaches?
19. Have you had regular dental examination in the past year?
20. Do you have any disease, condition, or problem not listed?
further to my consultation and direct consent. I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements including insurance or otherwise, have been made.

Summary

You will receive a 1 wk call/text/email with the dollar estimate of your treatment. You will receive a 3 day call/text/email so you can confirm your appt 2 days before to avoid a $75 short cancel fee. Lastly, because many people get sick the day before, you will also get a 1 day call/text/email so we can unschedule you and we can bring other patients for our doctors and hygienists. Thank-you for understanding. It is greatly appreciated.