New Patient Information

Please take your time to fill out this form completely. The more we learn about you, the better care we are able to provide. We look forward to working with you to maintain a healthy, happy smile.

First Name

Middle

Last Name

Nickname

Date of Birth

Address

City

State

Zip

Social Security Number

Home Phone

Work Phone

Cell Phone

Primary Contact Number (Please Check One)

Home Work Cell

Best Time to Call

Fax

Email address

Driver's License No.

Employer

Occupation

Spouse's Name

Spouse's Employer

Whom may we thank for referring you?

If the patient is a Child

School

School Phone

Grade

DENTAL HISTORY

Reason for Today's Visit

If so, Please Describe

Level of anxiety about seeing the dentist

1 (Least) 2 3 4 5 (Most)

Date of Last Dental Exam

Date of Last Cleaning

Date of Last Full Mouth X-Ray

Procedure(s) done at last dental visit

Previous Dentist's Name

City

State

Phone

Why are you changing dentists?

How often do you have dental examinations?

How often do you brush your teeth?

How often do you floss?

What type of Bristles do you use?

Hard Medium Soft

What other dental aids do you use? (Electric toothbrush, toothpick etc.)

Have you ever had?

If yes, Please describe

Is there anything else about your past dental treatment that you would like us to know?

MEDICAL HISTORY

If yes, for what?

Hospital or Physician's Name

Phone

Hospital or Physician's City

Hospital or Physician's State

If yes, Please explain

If so, How long ago?

If so, what are the problems?

Women Only:

Indicate which of the following you have had or have at present:

If Hepatitis, please indicate type:

Please list any serious medical condition(s) that you have ever had not listed above

If Other, Please specify

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Patient's Signature

Date

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