Adult Patient Form

Adult Patient Information

Date of birth


Do you wish to receive appointment reminders?

Just like phone calls and voicemails, texting may not always be 100% secure depending on the mobile service you use. Knowing that, would you like us to communicate with you via text?


Approximate date of last appointment?

Responsible Party Or Spouse

Primary Phone

Dental Insurance Information

Subscriber date of birth

Subscriber date of birth

Medical History

Last Visit

Have your tonsils or adenoids been removed?

Have you experienced jaw joint pain/discomfort? (TMJ/TMD)?

Do you have missing or extra permanent teeth?

Have you had an injury to?

Have you had gum disease or periodontal treatment?

Have you ever taken medications for treatment of Osteoporosis? (Fosamax, Boniva, etc.)

Do you have any sensory processing issues?

(Women) Are you pregnant?

Do you have speech problems?

Do you have any of the following habits?

Do your gums bleed?

Do you like your smile?



Do you smoke or chew tobacco?

Emergency Contact

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held to the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.