New Patient Form Please enable JavaScript in your browser to complete this form.Patient Information Patient Name *FirstLastName of Parent/Legal Guardian (if applicable):FirstLastLayoutSex: *MFOtherDate of Birth: *Email: *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhone Number (Cell) *Home/Other *LayoutOccupation / School: *Employer / company: *Emergency contact name: *FirstLastPhone Number: *Relationship: *How did you hear about us? *Insurance Information LayoutInsurance: *YesNoSubscriber Nameif yes, Insurance Provider:Date of birth:Relationship to Patient: SelfSpouseChildOtherLayoutGroup/Policy #:Certificate/ID #:Please note we only accept primary insurance; you are responsible for submitting to any secondary insurance. General Information Previous Dentists Name: (optional) Approximate Date of Your Last Hygiene Visit:What is the reason for your visit today? *Do you have an aesthetic concern about your smile? *Is there anything about your previous dental experience that we should be aware of? *Dental History Please indicate if you have any of the following: LayoutBad Breath *YesNoBleeding gums *YesNoCanker sores *YesNoFood collecting between certain teeth *YesNoHeadaches *YesNoClenching and/or grinding *YesNoDifficulty opening or closing *YesNoPrevious Ortho treatment *YesNoPrevious gum grafting *YesNoDental Implants *YesNoLoose teeth *YesNoLumps or growths in your mouth/face *YesNoPain in your joint, ear or side of face *YesNoSensitivity to hot, cold, sweet or chewing *YesNoMedical History LayoutFamily Doctor: Pharmacy:Have you ever had any serious illness or operation? *YesNo if yes, what, and when? Have you ever been tested for sleep apnea? *YesNoIf yes, what was the diagnosis?If applicable; LayoutAre you pregnant?YesNoDo you smoke? *YesNoAre you nursing?YesNoif yes:CigarettesVapeMarijuanaChewing tobaccoDo you use recreational drugs? *YesNoif yes, what?Have you ever been advised by a physician to take antibiotics before dental treatment? *YesNoMedication LayoutMedication (including vitamins)MedicationMedicationMedication Reason for taking? Reason for taking? Reason for taking? Reason for taking?Allergies LayoutPenicillin *YesNoLatex *YesNoCodeine *YesNoIbuprofen/Advil *YesNoOther (Please list ALL other allergies):Please indicate where you do or do not have any of the following conditions: LayoutTuberculosis *YesNoStroke *YesNoLayoutHeart problems *YesNoif yes, type:LayoutArtificial heart valve *YesNoFainting *YesNoBleeding abnormally/Hemophilia *YesNoAutism *YesNoArtificial joints, pins etc. *YesNoArthritis rheumatism *YesNoEpilepsy *YesNoAsthma/respiratory disease *YesNoHIV/AIDS *YesNoStomach or duodenal ulcer *YesNoLayoutCongenital heart lesions *YesNoif yes, type:Blood disease *YesNoif yes, type:Liver disease *YesNoif yes, type:Head/Neck injury *YesNoif yes, type:Kidney disease *YesNoif yes, type:Cancer *YesNoif yes, type:Autoimmune disorder *YesNoif yes, type:LayoutChemotherapy/Radiation *YesNoDrug dependency *YesNoAlcohol dependency *YesNoRheumatic/Scarlet fever *YesNoPacemaker *YesNoThyroid disease *Yes (Hypo)Yes (Hyper)NoLayoutDiabetes *YesNoif yes, type:LayoutHepatitis *YesNoif yes, type:Eating disorder *YesNoBlood pressure *Yes (High)Yes (Low)NoPlease list any additional medical conditions that may not be listed above: Authorization and Release *I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION TO THE BEST OF MY KNOWLEDGE. THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION INCLUDING THE DIAGNOSIS AND THE RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE TO THIRD PARTY PAYORS AND/OR HEALTH PRACTITIONERS. I CONSENT TO THE TAKING OF RADIOGRAPHS AND PHOTOGRAPHS BEFORE, DURING AND AFTER TREATMENT ON MY BEHALF OR MY DEPENENTS. I UNDERSTAND THAT MY DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED ON MY BEHALF OR MY DEPENDENTS.LayoutFull name of Patient/legal Guardian of Minor: *Date *Submit
