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New Patient Intake Form

 Patient Information

Registering for a child?

Contact Information

Emergency Contact

Contact Options

I prefer appointment reminders by
Are any other members of your family patients at our practice?

Insurance Information

Does insurance apply to you?

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

Are you being treated for any medical condition at the present or any time within the past year?
Has there been any change in your general health in the past year?
Are you taking any prescription, non-prescription medications, or herbal supplements?
Do you have any allergies?
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. infective endocarditis), a heart condition from birth, or a heart transplant?
Do you have a prosthetic or artificial joint?
Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Have you ever had hepatitis, jaundice, or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illnesses or operations?
Do you have, or have ever had any of the following? Please check
Are there any conditions/diseases not listed that you have or have had?
Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?
Do you smoke or chew tobacco products?
Are you nervous during dental treatment?
For women only: Are you pregnant or breastfeeding?

Dental History

How often do you see the dentist?
Have you ever whitened (bleached) your teeth?

Thanks for submitting!

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