Accepting New Patients!
Oral Cancer Screens
Inlays & Onlays
Full & Partial Dentures
Wisdom Teeth Extractions
Root Canal Therapy
Sleep Apnea Treatment
New Patient Form
5 Ways You Can Avoid Gum Disease
Differences Between Tooth Crowns and Fillings
Common Dental Emergencies
How to Treat Advanced Gum Disease
Why Should I Get a Dental Bridge
Why You May Need Wisdom Teeth Removal
Avoiding Time In The Dentist Chair
The Benefits of Dental Visits
Three Signs You Need Dental Implants
The Benefits of Porcelain Veneers
Can Brushing Teeth Ward Off Heart Disease
Invisalign vs Traditional Braces
Look Younger With Dental Implants
Dental Implant FAQ
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New Patient Form
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Name / Phone
Occupation / Height / Weight / Date of birth / Sex
SS# or Patient ID / Emergency Contact / Relationship / Phone
If you are completing this form for another person, what is your relationship to that person?
Do you have any of the following diseases or problems:
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often?
Are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Date of your last dental exam:
What was done at that time?
Date of last dental x-rays:
What is the reason for your dental visit today?
How do you feel about your smile?
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.
Signature of Patient/Legal Guardian:
Complete and Submit