New Patient Form

Patient Information

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

Mailing address

Occupation / Height / Weight / Date of birth / Sex

M F

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:

Active Tuberculosis

Yes No

Persistent cough greater than a 3 week duration

Yes No

Cough that produces blood

Yes No

Been exposed to anyone with tuberculosis

Yes No

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:

Date:

Patient Information

Dental Information

Dental Information