Fill out your dental health history form online.

For new patients only

Please fill out the form, then go to the Appointments section to schedule your first appointment.

Patient:

Date:

First Name: MI: Last Name:

Address:

Suite/Apt #

City: State: Zip Code:

D.O.B: SS# - -

Phone Number: ( ) -

E-Mail Address:

Marital Status:

Responsible Party:

First Name: MI: Last Name:

Address:

Suite/Apt #

City: State: Zip Code:

Phone Number: ( ) - SS# - -

Relation: Employer:

Business Address:

Work Phone: ( ) -

Insurance: Referred:

Chief Oral Complaint:

Date of last exam:
Have you had major dental treatment before? YES NO

If yes when, what?

Do you have or use any of the following:

Sensitive Teeth Bleeding Gums Food Impaction Clenching or Grinding Burning Tongue Swelling or Lumps in Mouth Blisters on Lips or Mouth Pain Around Ear Unusual Sounds While Eating Bad Breath Unpleasant Taste Unfavorable Dentist Experience	Complications From Extractions Periodontal Treatment Orthodontic Treatment Mouth Breathing Oral Habits Cigarettes/Pipe Smoking Texture of Toothbrushes Frequency of Brushing Dental Floss Inter Dental Stimulators Water Jet Device Disclosing Tablets/Solution Fluoride Supplements

Do You Have or Have You Had Any of the Following:

Allergies to Drugs

Allergies to Anesthetics

Any Heart Ailments

High Blood Pressure

Neurological Problems

Radiation Treatments

Bleeding From Cut/Extraction

Anemia/Blood Problems

Arthritis

Asthma

Hay Fever Allergies
Pregnancy if so Month:

Liver Problems/hepatitis
Kidney Problems
Malignancies
Psychiatric Care
Rheumatic Fever
Sinus Problems
Immune System Disorders
Stroke
Thyroid
Eye Disorders
Tonsillitis
Tuberculosis
Ulcer/Colitis
Diabetes
Venereal Disease
Other:

Describe any current medical treatment including drugs taken, even though not listed above:

APPOINTMENTS: A minimum charge will be made for failed or cancelled appointments without prior notification of 24 hours. This fee covers only a portion of the overhead such as salaries, electric, heat, etc. which still has to be paid whether you are present of not. Once an appointment is made please remember this time has been reserved for you.

INSURANCE: To avoid misunderstanding regarding dental insurance, we wish our patients to know that all professional services rendered are charged directly to the patient and that patients are personally responsible for payment of fees. We will prepare necessary forms or reports to help you obtain your benefits from insurance companies, upon receipt of full (or partial) payment of bill. We do not render our services on the basis that insurance companies will pay all our fees. Each fee is for the individual patient.

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