New Patient Forms - TMD Patient

Please correct the errors described below.

Patient Information

Emergency Contacts

Add Additional Emergency Contact

Financial Information

If "Someone Else" please fill out the information below:

Insurance Policy Information

If "Yes" please enter your policy information below, beginning with your Primary Insurance Policy.

Add Insurance Policy Information

Additional Information

Please list your preferred pharmacies in order of preference.

Add Pharmacy Information

Medical History

Please check all that apply.

If "Yes" please list all of your allergies to medications.

Add Medication Allergy

If "Yes" please list any medications you are currently taking.

Add Medication

Please list your healthcare providers, beginning with your primary care physician.

Add Healthcare Provider

Surgical History

Dental History

TMD Symptoms

Please mark the symptoms that you have had or are currently experiencing, by selecting the location on your head: Left side, Right side, or Both sides.

Head Pain

Ear Related Conditions

Jaw Related Conditions

Eye Related

Dental Related Conditions

History of Trauma

Injury to Head and/or Jaw

Add an Accident

Add personal injury

If "Yes" please list all injuries.

Add work injury

Acknowledgement of Receipt of Statement of Privacy Practices

Additional Disclosure Authorization

Authorization of Release

Your information will be encrypted.