New Patient Form

Save time at your first visit by filling out the form below.

PATIENT INFORMATION

Full Name

Sex

Preferred Name

Date of Birth

Age

Patient Street Address

City

State

Zip

Patient’s Hobbies / Interests

RESPONSIBLE PARTY INFORMATION

Full Name

Billing Party's Date of Birth

Relationship to Patient

Street Address

City

State

Zip

Employer

Cell Phone Number

Email

Marital Status

Partner's Name (if Applicable)

INSURANCE INFORMATION

Policy Holder's Name

Policy Holder Birthday

Policy Holder SS#

Policy Holder Employer

Insurance Company

Subscriber ID

Group #

MEDICAL/DENTAL HISTORY

General Dentist Name

Date of Last Dental Visit

Physician’s Name

Is the patient under the care of a physician for a specific reason at this time?

Comments:

Are you taking any prescription medication?

If yes, please list the medications.

Are you taking medications for osteoporosis or osteopenia?
If yes, please list the medications.

List any drug sensitivities:

Adolescent patients only: Has this patient reached puberty?

Have you been informed of any missing teeth?

Is there a family history of:
Sleep Apnea
Appliances to Improve Snoring
Palate Surgery
Jaw Surgery

If Surgery is an Option:

List Any Allergies

Are there any other family members that you would like us to evaluate?

Who may we thank for referring you to our office?

Signature

Today's Date

New Patient Form

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

MEDICAL/DENTAL HISTORY​​​​

MEDICAL/DENTAL HISTORY