New Patient Form

Patient Information

Name

Birth date

Health card #

Email address

Cell phone

Home phone

Work phone

Street address

City

Postal code

Marital status

Single Married Child Other

If Other, please describe

Employer

Whom may we thank for referring you?

Emergency contact name

Emergency contact phone

Relationship

Responsible Party

Name of person responsible for this account

Relationship

Address

Home phone

Cell phone

Work phone

Employer

Is this person currently a patient in our office?

Yes No

Patient Medical History

Who is your current physician?

Phone

When was your last checkup?

1. Are you under medical treatment at this time?

Yes No

If yes, please explain

2. Do you consider yourself to be in good health?

Yes No

3. Have you ever been hospitalized for any surgery/illness?

Yes No

If yes, please explain

4. Are you taking any medication(s) including non-prescription medicine?

Yes No

If yes, please list below:

5. Do you smoke or chew tobacco?

Yes No

6. Are you allergic to or have you had reactions to any of the following:

Local anesthetic

Sulfa drugs

Penicillin or other antibiotics

Aspirin

Other

If other, please describe

For females only:

Are you pregnant or think you may be pregnant?

Yes No

Are you taking birth control pills?

Yes No

If other, please explain:

Patient Dental History

1. Do you clench/grind your teeth?

Yes No

2. Do you feel pain in any of your teeth?

Yes No

3. Do your gums bleed during brushing/flossing?

Yes No

4. Have you had any prolonged bleeding following extractions?

Yes No

5. Have you had any head, jaw or neck injuries?

Yes No

6. Have you experienced jaw clicking, difficulty opening, closing the mouth or difficulty chewing?

Yes No

7. Have you had any orthodontic work?

Yes No

8. Do you experience frequent headaches?

Yes No

9. Have you ever had instruction on the correct method of brushing your teeth/caring for your gums?

Yes No

10. Are you happy with the appearance of your smile?

Yes No

11. Do you feel that you may have bad breath?

Yes No

12. Please tell us any concerns you may have about your teeth

Authorization & Release

I certify that I have read, understood & completed the personal, medical, and dental histories to the best of my knowledge, and have not knowingly omitted any information. I am aware that providing incorrect information can be dangerous to my health. I authorize the dentist & staff to release the record of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners which may be submitted electronically. I understand that I am financially responsible to the dentist for the dental services provided even if my insurance coverage may not be inclusive.

Signature of patient or parent if minor

Please type your full name

Date

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