New Patient Form

First Name*
Last Name*
Address*
US State
Home Phone*
Cell Phone / Other
Date of Birth:*
Social Security Number
If patient is a minor, give parent's or guardian's name
Telephone #
Primary Subscriber's Name(2)
Primary Subscriber's Social Security Number (U.S. only) OR Member ID number
Insurance Company
Phone Number
Secondary Subscriber's Name
Employer or Group Name:
Secondary Insurance Company
Secondary Insurance Phone Number
Street
State/Province
Country
Physician
Street:
State/Province:
Are you taking any medication?
Comment
Do you have a history of any major illness?
Comment..
Have you ever been involved in a serious accident?
Middle Name
Nickname
City
Zip Code
Work Phone
Email*
Gender:
Whom may we thank for referring you to our office?
Other family members seen by us
Primary Subscriber's Date Of Birth
Employer or Group Name
Group Number
Do you have dual coverage?
Secondary Subscriber's Date of Birth
Secondary Subscriber's Social Security Number (U.S. only) OR Member ID number
Secondary Insurance Group Number
Name of the nearest relative not living with you
City:
Zip/Postal Code
Phone
Date of Last Visit
Country:
City.
Phone.
Are you allergic to any medication?
Comment.
Have you had any major operations?
Comment...
Comment....

----- Please check any of the following that you have had or currently have -----

-
Are there any medical conditions we have not discussed that you feel we should be aware of?
--
If yes, please state:
----- Dental History -----
General Dentist
What concerns you most about your teeth?
Date of Last Visit:

Please check any of the following which apply to you, and add any relevant comments

.
I have another question or concern. (please state)
----- Signature -----
By entering my name I understand the above information is necessary to provide me with dental care in a safe and efficient manner.*
Date:*
----- Financial Responsibility -----
By entering my name, I understand that all responsibility for payment for dental services provided in this office for myself or dependents is mine, due and payable at the time services are rendered unless other arrangements are made.* *

By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.