New Patient Form

Patient Information

Patient Full Name *

Residence Address

Address Line 1 *

Address Line 2

City *

ZIP Code *

Date of Birth *

State *

Country *

Residence/Cell Phone *

Email Address

Nearest Relative not living with you (name, address, phone)

Is the patient a minor? (Under 18) *

Yes No

Name of Spouse/Parent (if a minor)

Additional Information

General Dentist Name & Phone

Whom may we thank for referring you?

Dental Insurance Information

Employee/Primary Insured Name

Employer & Occupation

Insured's Date of Birth

Relationship to Patient

Insurance ID Number

Insurance Phone Number

Insurance Company & Contact Information

Please include claims address and phone number.

Are you covered by a secondary insurance company?

Yes No

If Yes: Secondary Insurance Information

Please provide the Insurance Company, ID Number, Insurance Company Address & Contact information.

Preferred Pharmacy Contact Info

Please include name, phone number and address of your preferred pharmacy.

Medical History

Are you in good health? If not, explain: *

Has there been any change in your general health within the past year? Please specify: *

Are you taking any medicine(s) including non-prescription medicine? If so, what medicine(s) are you taking? *

Have you had or currently have any of the following?

High blood pressure *

Yes No

Heart murmur or prolapsed valve *

Yes No

Rheumatic fever or rheumatic heart disease *

Yes No

Congenital heart disease *

Yes No

Sinus trouble *

Yes No

Asthma or hay fever *

Yes No

Diabetes *

Yes No

Hepatitis, jaundice or liver disease *

Yes No

Fainting spells or seizures *

Yes No

Arthritis *

Yes No

Artificial joints *

Yes No

Temporomandibular joint problems (TMJ) *

Yes No

Cardiovascular disease: heart attack, stroke *

Yes No

Prosthetic heart valve *

Yes No

Blood disorder (i.e. Anemia) *

Yes No

Cosmetic Surgery *

Yes No

Kidney trouble *

Yes No

Thyroid *

Yes No

Tuberculosis *

Yes No

Persistent cough *

Yes No

Stomach ulcers *

Yes No

Cancer *

Yes No

HIV/AIDS or immunosuppressive disorder *

Yes No

Medical Information Updates

Are you allergic or have you had a reaction to any drug or medicine? If so, what? *

Do you smoke? If so, how much and for how long? *

Do you take any medication for osteoporosis or osteopenia? *

Are you taking birth control pills or hormones? *

Yes No

Are you pregnant/nursing? *

Yes No

Financial Responsibility (required)
Payment for today’s visit and future visits is due at time of service. We may accept assignment of benefits and will submit your claims as a courtesy to you. If you have insurance, the amount quoted prior to treatment is our best estimate based on what your insurance provider tells us. The balance is your responsibility regardless of your insurance benefit. Your insurance policy is a contract between you and your insurance company. We will do our best to make the most of your insurance benefit. Thank you for understanding our Financial Policy.

I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I also understand that I am responsible for any interest (1.5% per month), collection fees (an additional 40% added to balance), reasonable attorney fees and court costs that may occur due to non-compliance of these terms.

Acknowledgement (required)

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. If necessary, this office may share medical/dental information with your dentist or other specialists to help consult with what treatment may be best for you.

Digital Signature *

Please type your full name and the date as a signature to this form.