Contact Us

Patient Information

Patient Name*:

Date: (dd/mm/yyyy)

Address:

City:

State:

Zip:

Gender: MaleFemale       Birth Date: (dd/mm/yyyy)

Family Status:

Driver’s License #:

Phone(Home):

Phone(Work):

Phone(Mobile):

Preferred appointment times:

MorningAfternoonEveningAny TimeMTWTFS

Email*    Receive appointment reminders? YesNo

Referral Information

Whom may we thank for referring you to our practice?

Another patient, friendAnother patient, relativeDental OfficeYellow PagesNewspaperSchoolWorkOther

Name of person or office referring you to our practice:

Dental History

Please check any of the following problems that apply to you:

Sensitivity (Hot, Cold, Sweet)
Headaches, earaches, neck pain
Jaw Joint Pain
Teeth or fillings breaking
Grinding or clenching teeth
Bleeding, swollen or irritated gums
Loose, tipped or shifting teeth
Bad breath

Do you have or have you had any of the following?

Dentures
Partial Dentures
Braces
Periodontal (gum) treatments

Please share the following dates:

Your last cleaning:

(dd/mm/yyyy)

Your last oral cancer screening:

(dd/mm/yyyy)

Your last complete X-Rays:

(dd/mm/yyyy)

If you could whiten your teeth for a cost anyone could afford, would you do it? YesNo

Do you smoke or use chewing tobacco? YesNo

If I could change my smile, I would:

Make them whiter
Make them straighter
Close spaces
Replace black metal fillings with tooth colored restorations
Repair chipped teeth
Replace missing teeth
Replace old crowns that don’t match
Have a smile makeover

On a scale of 1 – 10, with 10 being the highest rating:

How important is your dental health to you?
12345678910
Where would you rate your current dental health?
12345678910
Where do you want your dental health to be?
12345678910

Name of Previous Dentist:

City:

State:

Phone Number:

What is the most important thing to you about your future smile and dental health?

What is your most important thing to you about your dental visit today?

Why did you leave your previous dentist?

Health Information

Do you have any of the following allergies?

Aspirin
Codeine
Local Anesthetic
Erythromycin
Penicillin
Sulfa
Tetracycline
Metals
Latex
Other

Have you ever had any of the following? Please check those that apply:

AIDS
Anemia
Arthritis
Artificial Heart Valve
Artificial Joints
Asthma
Blood Disease
Bruise Easily
Cancer
Chemotherapy
Diabetes
Dizziness
Drug Addiction
Emphysema
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Growths
Hay Fever
Head Injuries
Heart Conditions
Heart Disease
Heart Lesions
Heart Murmur
Heart Surgery
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Epilepsy
HIV Positive
Jaundice
Jaw Joint Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorders
Mitral Valve Prolapse
Nervous Disorders
Pacemaker
Pregnancy
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Scarlet Fever
Seizures
Sinus Problems
Stomach Problems
Stroke
Thyroid Disease
Tuberculosis
Tumors
Ulcers
Venereal Disease
OTHER

Have you ever had any complications following dental treatment?
YesNo

Have you been admitted to a hospital or needed emergency care during the past two years?
YesNo

Are you now under the care of a physician?
YesNo

Are you currently taking any medications?
YesNo

Spouse or Responsible Party Information

The following is for:
the patient's spousethe person responsible for payment

Insurance Information

Name of Insured:

Is insured a patient?
YesNo

Insured's Birth Date: (dd/mm/yyyy)

Insured's Address:

Insured's Employer Name:

Insured's Employer Address: