Patient Information Sheet

This is our New Patient Information Sheet. Please complete prior to your first visit to ensure a fast check in.

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Contact Info

First Name:
Last Name:
Preferred Name:
Date of Birth:
Marital Status:
Home Address:
Home #:
Cell #:
Work #:
Preferred Method of Contact:

Account Holder Information

Person responsible for account:
Address if different from above:
Previous Address:
Previous Phone #:
How did you hear about us?
If you were referred by a physician please provide their name:
Dental Insurance (We will need a copy of your current card at your scheduled visit):
Local No. (Union) if applicable:

Appointment Information

Purpose of visit:
Preferred day for appointments:
Preferred time for appointments:

Medical History

Are you under a physician's care or medical treatment now?
If yes, reason for treatment?
Are you pregnant?
Are you currently taking any birth control medication?
Have you ever taken Fen-phen, Redux or other diet assisting medicines?
Are you taking any medication(s), including any over the counter?
If yes, please list:
Have you ever had any of theses problems/issues? Check all that apply.

Diagnosed when?
Do you PREMEDICATE for any reason?
Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 wks)?If yes, please describe:
Have you ever had any unusual/bad/adverse reaction/response to any drug including penicillin or aspirin?If yes, what?
Do you have any allergy or reaction to latex?
Have you ever had a reaction to a dental anesthetic?
Have you ever had trouble with prolonged bleeding after surgery?If yes, when?
Is there any other information that we should know about any previous dental visits?
Is there any other information that we should know about your health?
Have you had any of these surgeries? Select all that apply.

If yes please indicate date/type of your surgery.
Have you ever had an organ transplant?
Which organ?


Electronic Signature (type name):