New Patient Form

Name *
Name
Date *
Date
Birthdate *
Birthdate
Phone Number *
Phone Number
Address *
Address
Select Your Gender *
Receive Email & Text Correspondence *
Work Phone
Work Phone
Person To Contact In Case of Emergency *
Person To Contact In Case of Emergency
Emergency Contact Phone Number *
Emergency Contact Phone Number
Responsible Party (if different from above)
Name of Person Responsible for this Account *
Name of Person Responsible for this Account
Birthdate *
Birthdate
Phone Number *
Phone Number
Address
Address
Work Phone Number
Work Phone Number
As a courtesy we will submit services rendered to your insurance carrier. Your portion is due in full at time of service. I understand that my dental insurance carrier may pay less than the actual bill for service. I agree to be responsible for payment of all services rendered on my behalf or my dependents. If you wish to discuss the office's payment policy, please ask us and we will be happy to help.
Dental Insurance Information
Name of Insured *
Name of Insured
Birthdate *
Birthdate
Date Employed *
Date Employed
Phone Number *
Phone Number
Do You Have any Additional Dental Insurance? (If yes, then complete the following)
Name of Insured *
Name of Insured
Birthdate *
Birthdate
Date Employed
Date Employed
Phone Number *
Phone Number
Medical Insurance Information
Name of Insured *
Name of Insured
Birthdate *
Birthdate
Date Employed
Date Employed
Phone Number *
Phone Number
Do You Have any Additional Medical Insurance? (If yes, then complete the following)
Name of Insured *
Name of Insured
Birthdate *
Birthdate
Date Employed
Date Employed
Phone Number *
Phone Number
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Please answer the following questions.
Are you under a physician's care now? *
Have you ever been hospitalized or had a major operation? *
Have you ever had a serious head or neck injury? *
Are you taking any medications, pill, or drugs? *
Do you take, or have you taken, Fosamax, Actonel, or Boniva? (Commonly taken for Osteoporosis) *
Do you use tobacco? *
Do you use controlled substances? *
Do you snore or have been told that you snore? *
Have you been diagnosed with Sleep Apnea? *
Do you wear a C-PAP or have you in the past? Have you been told to? *
Have you had a sleep study or been told to get a sleep study? *
Are you allergic to the following?
WOMEN: Are you (Check for yes, leave blank for no)
Do you have any of the following? (Check those that apply)
Have you ever had any serious illness not listed above? *