New Patient Form Please fill out the form below, or download and return this PDF document. Step 1 of 4 - Patient/Insurance Information 25% Patient InformationFirst Name* First Middle Initial* Middle Last Name* Last Phone*Email* SSN*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Sex*MaleFemaleUnspecifiedMarital Status*SingleMarriedWidowedSeparatedDivorcedBirthdate* MM slash DD slash YYYY Patient EmployerOccupationWork PhoneHow would you like to be notified for upcoming appointments? Email Phone Text Mobile Carrier (to receive text messages for appointments):Insurance InformationAny Dental Insurance Coverage?*YesNoWho is your carrier?*ID number/Social #*Person Responsible for Account*Relation to PatientBirthdate MM slash DD slash YYYY PhoneAddress (if different from patient's) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PermissionEmergency Contact*Emergency Contact Relation*Emergency Contact Phone* Patient Medical HistoryName of Physician and their specialty:*Most recent Physical Examination: MM slash DD slash YYYY Pupose of Last Medical Exam:What is your estimate of your general health?ExcellentGoodFairPoorDo you have or have you ever had:1. Hospitalization for illness or injury?* Yes No 2. An allergic or bad reaction to any of the following:* Aspirin (ibuprofen, acetaminophen, codine) Penicillin Erythromycin Tetracycline Sulfa Local anesthetic Flouride Chlorhexidine (CHX) Iodine Metals (nickle, gold, silver) Latex Nuts Fruit Milk Red dye Other No Known Allergies 3. Heart problems,or cardiac stent within the last 6 mo.* Yes No 4. History of infective endocarditis* Yes No 5. Artificial hearth valve, repaired heart defect (PFO)* Yes No 6. Pacemaker or implantable defibrillator* Yes No 7. Autoimmune disease (e.g rheumatoid arthritis, lupus, scleroderma)* Yes No 7. Orthopedic or soft tissure implant (e.g joint replacement, breast implant* Yes No 8. Heart mumur, rheumatic or scarlet fever* Yes No 9. High or low blood pressure* Yes - high blood pressure Yes - low blood pressure No 10. A stroke (taking blood thinners)* Yes No 11. Anemia or other blood disorder* Yes No 12. Prolonged bleeding due to a slight cut (or INR > 3.5)* Yes No 13. Pneumonia, emphysema, shortness of breath, sarcoidosis* Yes No 14. Chronic ear infections, tuberculosis, measles, chicken pox* Yes No 15. Breathing problems (e.g asthma, stuffy nose, sinus congestion)* Yes No 16. Sleep problems (e.g sleep apnea, snoring, insomnia, restless sleep, bedwetting)* Yes No 17. Kidney disease* Yes No 18. Liver disease or jaundice* Yes No 19. Vertigo (e.g “the room is spinning)* Yes No 20. Thyroid, parathyroid disease, or calcium deficiency* Yes No 21. Hormone deficiency or imbalance (e.g poly cistic ovarian syndrome)* Yes No 22. High cholesterol or taking statin drugs* Yes No 23. Diabetes* Yes No 24. Stomach or duodenal ulcer* Yes No 25. Digestive or eating disorders (e.g cliac disease, gastric reflux, bulimia, anorexia)* Yes No 26. Osetoporosis/ osteopenia oor ever taken anti- resorptive medications (e.g bisphosphonates)* Yes No 27. Arthritis or Gout* Yes No 28. Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)* Yes No 29. Glaucoma* Yes No 30. Contact lenses* Yes No 31. Head or neck injuries* Yes No 32. Epilepsy, convulsons (seizures)* Yes No 33. Neurologic disorders (e.g alzheimer’s disease, dementia, prion disease)* Yes No 34. Viral infections and cold sores* Yes No 35. Any lumps or swelling in the mouth* Yes No 36. Hives, skin rash, hay fever* Yes No 37. STI/STD/HPV* Yes No 38. Hepatitis* Yes No 39. HIV/AIDS* Yes No 40. Tumor, abnormal growth* Yes No 41. Radiation therapy* Yes No 42. Chemotherapy, immunosuppressive medication* Yes No 43. Emotional difficulties* Yes No 44. Psychiatric treatment or antidepressant medication* Yes No 45. Concentration problems or ADD/ADHD* Yes No 46. Alcohol/ recreational drug use* Yes No Are you:47. Presently being treated for any other illness?* Yes No 48. Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)?* Yes No 49. Taking medication for weight management?* Yes No 50. Taking dietary supplements, vitamins, and/or probiotics?* Yes No 51. Often exhausted or fatigued?* Yes No 52. Experiencing frequent headaches or chronic pain?* Yes No 53. A smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis)?* Yes No 54. Considered a touchy/sensitive person?* Yes No 55. Often unhappy or depressed?* Yes No 56. Taking birth control pills?* Yes No 57. Currently pregnant?* Yes No 58. Diagnosed with a prostate disorder?* Yes No Describe any current medical treatment, impending surgery, genetic/ development delay, or other treatment that may possibly affect your dental treatmentList all medications, supplements, vitamins, and/ or probiotics taken currently:* AuthorizationConsent* I agree to the below statement.I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me I authorize the use of the signature on all insurance submissions. I understand this practice’s Notice of Privacy Practices written in plain language. This notice provides the usage of Initial disclosure of my health information as protected by HIPAA. I understand this office has the right to alter this privacy in regards to my health information. If changes occur this Initial practice will provide me with a revised notice of the privacy policy upon my request. I instruct the dentist and/or hygienist to deliver the care that, in their professional judgement, can best help me in the Initial restoration of my health.Consent I agree to the below statement.I consent to allow photographs and/or x-rays to be used for demonstrations, marketing material, patient education, etc. Consent* I agree to the below statement.I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions. Consent* I agree to the below statement.I have answered all questions regarding myself, or my dependent's medical history and present health condition fully and truthfully, including allergies. I also understand if there are any changes in my, or my dependents health I am to inform the doctor at my next appointment. Consent* I agree to the below statement.I agree to provide a minimum of 24 hour notice if I need to change my appointment for any reason. I understand if I fail an appointment I may be charged a fee. Failure to show for a second appointment may result in dismissal from the practice. Consent* I agree to the below statement.I instruct the dentist to deliver care that, in their professional judgement, is necessary in the restoration of my health once they've been discovered and discussed. Consent* I agree to the below statement.State and federal laws require us to maintain the privacy or your health information and to inform you about our privacy practices by providing you with a Notice of Privacy Practices. This form is available online for your convenience, if you prefer a paper copy, please feel free to contact us. Whom may we thank for referring you/ how did you hear about us?*Full Name*Date* MM slash DD slash YYYY
