New Patient Form

Dental Information

Reason for today's visit: ExamEmergencyConsultation
 
Are you in Pain: YesNo
 
Please indicate any of the following problems: Discomfort, clicking or popping in jawRed, swollen or bleeding gumsSensitive tooth, teeth or gumsBlister/Sores in or around the mouthLost/Broken filling(s)Teeth grindingRinging in earsBroken/Chipped toothStained teethLocking jawBad bread
 
Do you require pre-medication? YesNoI don't know
 
Last Dental Exam: Last Dental X-Rays:
 
What type of tooth brush bristles do you use? SoftMediumHard

Medical History

What Medications are you taking?
 
Nerve pillsPain killers (including Aspirin)Muscle relaxersStimulantsBlood thinnersTranquilizersInsulinMeds for Osteoporosis
 
Have you ever taken:
 
Bisphosphonates (ex. Aredia/Fosamax) YesNo
 
Phen-fen/Redux YesNo
 
Do you have or have had any of the following deseases, medical conditions or procedures?
 
Heart attack / StrokeHeart Surgery / PacemakerHeart MurmurRheumatic FeverMitral Valve ProlapseArtificial ValvesHeart DiseaseCongenital Heart DefectChest PainsScarlet FeverNervousnessThyroid ProblemsKidney ProblemsLiver ProblemsRespiratory ProblemsSinus ProblemsStomach Problems / UlcersPsychiatric ProblemsVenereal DiseaseAlcohol / Drug AbuseTuberculosis TBJaw Problems TMJ/TMDCancer / TumorsShinglesHepatitisHIV+ / AIDS / ARCArthritis / RheumatismArtificial Bones / JointsEmphysemaFainting / Seizures / EpilepsySevere / Frequent HeadachesFrequent Neck PainBack ProblemsCosmetic SurgeryXray or Cobalt TreatmentChemotherapyAsthmaDifficulty BreathingDiabetes / HypoglycemiaLeukemiaAnemiaHigh / Low Blood PressureBleeding ProblemsGlaucoma
 
Are you allergic to any of the following:
 
LatexPenicillin / AmoxicillinTetracyclineAspirinDental Anesthetics
 
Do you use tobacco? YesNo

For Women

Are you taking birth control pills? YesNo
 
Are you pregnant? YesNo
 
Are you nursing? YesNo
 
  • We invite you to discuss with any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between provider and patient.
  • Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.
  • I authorize the staff to perform any necessary services needed dyeing the diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
  • I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
I acknowledge that I have received a copy of the Summary of Privacy Notice.
 

 
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