New Dental Patient Form

Hyattsville Cosmetic Dentistry

(301)-559-3668

Patient Information

First name

Last name

Home phone number

Cell phone number

Email address

Date of birth

Insurance Information

Name of insurance policy holder

Policy/plan number

Dental History

Date of last dental visit

Date of last dental cleaning

Date of last dental x-rays

Do you smoke or chew tobacco?

Please check any of the following problems that might apply to you

Tooth pain or discomfort while chewing

Loose, tipped, or shifting teeth

Grinding or clenching teeth

Bleeding teeth or fillings

Broken teeth or fillings

Headaches, earaches, or neck pain

Jaw joint pain

Sensitivity (hot, cold and/or sweet)

Do you have or have you ever had any of the following?

Dentures

Braces

Periodontal (gum) treatments

Difficult extractions

Medical History

Do you have any of the following allergies?

Penicillin

Aspirin

Codeine

Latex

Local anesthetic

Percocet

Sulpha

Valium

Other

Your Smile

If you could change your smile you would...

Make your teeth brighter

Make your teeth straighter

Close spaces

Replace black metal fillings with natural, tooth colored fillings

Repair chipped teeth

Replace missing teeth

Have a smile makeover

Replace old crowns that don't match

Emergency Contact Information

Add another emergency contact

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Dr. Brian Moore

DDS

Make us your dental partner for life and discover a more convenient and affordable way to secure essential dental services. As a dentist with more than 30 years of experience, we take pride in offering the most extensive local selection of treatments for adults, children, and seniors.

+1-301-559-3668
hyattsvillecosmeticdentistry.com
Hyattsville-Cosmetic-Dentistry-1231838780273653
Chicago, Illinois, US