Patient Forms

Thank you in advance for the trust you have placed in our office. Below is a download for new patient forms. Please print them, fill them out and bring them with you to your first appointment. This Will allow us more time to devote to your dental needs.

Please call the office if you have any questions. We are looking forward to meeting you.

Or if you prefer, you can complete the forms online.
Your data will arrive in an email from our office.

This field is completed by the clinic
 
Check appropriate box:
RESPONSIBLE PATIENT
Is this person currently a patient in our office?
For you convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.
DO YOU HAVE ANY ADDITIONAL INSURANCE?
1. Are you under medical treatment now?
2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? If yes, please explain.
3. Are you taking any medication(s) including non-prescription medicine? If yes, please list the medication(s).
4. Have you ever taken Fen-Phen/Redux?
5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?
6. Have you ever taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?
7. Do you use tobacco?
8. Do you use controlled substances?
9. Do you have or have you had any of the following?
High Blood Pressure
Heart Attack
Rheumatic Fever
Swollen Ankles
Fainting / Seizures
Asthma
Low Blood Pressure
Epilepsy / Convulsions
Leukemia
Diabetes
Kidney Diseases
AIDS or HIV Infection
Thyroid Problem
Heart Disease
Cardiac Pacemaker
Heart Murmur
Angina
Frequently Tired
Anemia
Emphysema
Cancer
Arthritis
Joint Replacement or Implant
Hepatitis / Jaundice
Sexually Transmitted Disease
Stomach Troubles / Ulcers
Chest Pains
Easily Winded
Stroke
Hay Fever / Allergies
Tuberculosis
Radiation Therapy
Glaucoma
Recent Weight Loss
Liver Disease
Heart Trouble
Respiratory Problems
Mitral Valve Prolapse
10. Are you wearing contact lenses?
11. Are you allergic to or have you had any reactions to the following?
12. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?
13. Women only. Are you a woman?
Are you pregnant or think you may be pregnant?
Are you nursing?
Are you taking oral contraceptives?
PATIENT DENTAL HISTORY
1. Do your gums bleed while brushing or flossing?
2. Are your teeth sensitive to hot or cold liquids/foods?
3. Are your teeth sensitive to sweet or sour liquids/foods?
4. Do you feel pain to any of your teeth?
5. Do you have any sores or lumps in or near your mouth?
6. Have you had any head, neck or jaw injuries?
7. Have you ever experienced any of the following problems in your jaw?
8. Do you have frequent headaches?
9. Do you clench or grind your teeth?
10. Do you bite your lips or cheeks frequently?
11. Have you ever had any difficult extractions in the past?
12. Have you ever had any prolonged bleeding following extractions?
13. Have you had any orthodontic treatment?
14. Do you wear dentures or partials?
15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
16. Do you like your smile?

Quick appointment request

Appointments are not confirmed until the office reaches out to confirm your information. f you have any questions, please contact us here.