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New Patient Form

Please fill out the following form
in order to expedite your appointment.

Gender
Medical History

Mark the corresponding box next to any of the following illnesses you have had:

Mark the corresponding box next to any of the following medications you are taking or have a reaction to:

Please list the name(s) of the medications and dosage:

Do you smoke?
Do you consume alcoholic beverages?
Do you have skin problems? Required
Have you or any member of your family ever had bleeding problems? Required
Have you had prolonged bleeding afte surgery or tooth extraction? Required
Have you ever had convulsions or fainting spells? Required
Do you wake with unusual thirst or need to urinate? Required
Do you have headaches more than twice a week? Required
Do you have any cardivascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion)? Required
Have you been bothered by a thumping or racing heart? Required
Does very little effort leave you short of breath? Required
Do you have damaged heart valves or artificial heart valves? Required
Have you ever been told you have a heart murmor? Required
Have you ever had surgery or radiation treatment for a tumor or growth? Required
Have you been under a physician's care within the last year? Required
Are you now under the care of a physician? Required
Have you ever been hospitalized for any serious medical iillness or operation? Required
Have you ever had a prosthetic implanted (heart valve, joint. replacement)? Required
Do your gums ever bleed when you brush your teeth? Required
Do you ever have bad taste in your mouth? Required
Are your gums receding (root exposure)? Required
Are your teeth sensitive to hot or cold? Required
Do you suffer from pain and/or swelling of your gums (abcesses)? Required
Have you noticed any loosening of you teeth? Required
Do you ever find yourself clenching and/or grinding your teeth? Required
Have you ever had a bad reaction to dental anesthetic (Novacaine)? Required
Have you ever had any complications following dental surgery? Required
Do you gag easily? Required
Do you have trouble relaxing during a dental visit? Required
Do you use: Required

For Women Only

Are you presently taking birth control?
Have you gone through or are presently going through menopause?
Are you pregnant or trying to become pregnant at the present time?

Insurance Information

Upload Insurance Card
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Comments

I understand that if I cancel an appointment without giving at least twenty-four (24) hours notice I will be billed $50. I agree to pay this broken appointment fee within 30 days of the date of the broken appointment.

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I certify that the above health history is accurate and I will notify you of any change in my physical condition.

Upload Driver's License
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Thanks for submitting!

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