Welcome We are pleased to welcome you and your family to our practice. Please take a few minutes to fill out your new patient forms. If you have questions, we will be glad to help you. We look forward to working with you in maintaining your dental health. Date SS/HIC/Patient ID # Patient Name Address Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country SexMF StatusMarriedWidowedSingleMinorSeparatedDivorcedPartnered Occupation Patient Employer/ School Employer/School Address Spouse's Name Date of Birth01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year SS# Age Spouse's Employer Whom may we thank for referring you? Subscriber's Name Relationship to Patient Birth date01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year SS # Insurance Co. Group# Phone Is patient covered by secondary insurance? YesNo Subscriber Name Relationship To Patient Birthdate01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year SS # Insurance Co. Group# Phone Reason for today's visit Former Dentist City/State Date of last dental visit Date of last dental X-rays How often do you floss? How often do you brush? Do you wear contact lenses?YesNo Please check "yes" or "no" to indicate if you have had any of the following:YesNoBad breathBleeding GumsBlisters on lips or mouthBurning sensation on tongueChew on one side of mouthCigarette, pipe, or cigar smokingClicking on popping jawDry mouthFingernail bitingFood collection between the teethForeign objects in mouthGrinding teethGums swollen or tenderJaw Pain or tirednessLip or cheek bitingLoose teeth or broken fillingsMouth breathingMouth painOrthodontic treatmentPain around earPeriodontal treatmentSensitivity to coldSensitivity to heatSensitivity to sweetSensitivity when bitingSores or growths in mouth Please check "Yes" or "No" to indicate if you have had any of the following:YesNoAIDSAnemiaArthritis, RheumatismAsthmaBack ProblemsCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, presistent or bloodyDiabetesEpilepsyFainting or dizzinessGlaucomaHeadachesHeart ProblemsHepatitis TypeHerpes Have you ever had any complications following dental treatments?YesNo If yes, please describe Have you ever been hospitalized or do you have any other health concerns? YesNo If yes, please Describe Women: Are you pregnant?YesNo Due date Please check "Yes" or "No" to indicate if you have had any of the following :YesNoHigh Blood PressureHIV PositiveJaundiceJaw PainKidney DiseaseLiver DiseaseLow Blood PressureNervous problemsPsychiatric CareRadiation TreatmentRespiratory DiseaseScarlet FeverShortness of BreathSinus TroubleSkin RashSpecial Diet/ Weight LossStrokeSwollen Feet or AnklesSwollen Neck GlandsThyroid Problems Have you ever taken any of these medications?YesNoBlood ThinnersCoumadinWarfarinDiet MedicationsDexfenfluramineFen-phenPondiminReduxLevoxylSynthroid Please print all medications now taking: Please check "Yes" or "No" to indicate if you have had any of the following -YesNoTonsillitisTuberculosisTumors or GrowthsUlcerVenereal Disease Have you ever had or been diagnosed with:YesNoArtificial Heart ValvesArtificial Joints, Screws, Pins etc.Bleeding abnormally with extractions or surgeryBlood DiseaseCongenital Heart LesionsHeart MurmurHernia RepairMitral Valve ProlapsePacemakerRheumatic Fever Are you allergic to:YesNoAspirinBarbituratesCodeineIbuprofenLatexLocal AnesthesiaMetals (i.e. gold)Penicillin Others Are you nursing?YesNo Taking birth control pills?YesNo Privacy policy*By checking this box you are accepting that you have read and agreed to our Hippa, Privacy Policy, Terms & Conditions as well as Financial Policy located at the bottom of the page.SubmitReset
