|
This is our New Patient Information Sheet. Please complete prior to your first visit to ensure a fast check in.
Provide us with feedback | Request an Appointment
|
Contact Info
|
|
First Name:
First Name Required
|
Last Name:
Last Name Required
|
Preferred Name:
|
Date of Birth:
|
Marital Status:
|
Home Address:
home address Required
|
Email:
Email Required
|
Home #:
|
Cell #:
|
Work #:
|
Preferred Method of Contact:
prefer meth of contact Required
|
Employer:
Employer Required
|
Occupation:
Occupation Required
|
| |
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:
prefer appt time Required
|
| |
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.
|
|
|
| Other:
|
|
|
|
| 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?
|
When?
|
| |
Signature
|
|
Electronic Signature (type name):
|
Date:
|