New Patient Information

Please fill out the form below if you are a new patient before your visit
or you can also download the FORM.

Today's Date
Today's Date
Birthday
Birthday
Name
Name
Home Address
Home Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Spouse's Information
Name
Name
Birthday
Birthday
Work Phone
Work Phone
Address 1
Address 1
Primary Insurance
Claims Address
Claims Address
Insurance Company Phone
Insurance Company Phone
Name of Insured
Name of Insured
Secondary Insurance
Claims Address
Claims Address
Insurance Company Phone
Insurance Company Phone
Name of Insured
Name of Insured
Birthday of Insured
Birthday of Insured
In case of Emergency ( Please Provide the following for a friend or family member not living with you )
Name
Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Medical History
Name of Physician
Name of Physician
Phone
Phone
DO YOU HAVE OR HAVE EVER HAD ANY OF THE FOLLOWING? PLEASE CHECK THOSE THAT APPLY:
* This condition may require antibiotic premedication for certain dental procedures.
Do you have any health problems that were not listed above or need further clarifications?
Are you now under the care of a physician? *
Have you been admitted to a hospital or needed emergency care during the past two years?
Are you taking any medications or herbals? *
Are you allergic to any medications or substances? *
If yes, check box below:
Have you used tobacco?
DO YOU HAVE OR HAVE EVER HAD ANY OF THE FOLLOWING? PLEASE CHECK THOSE THAT APPLY:
Women (Please Check)
Antibiotics that have been shown to interact with birth control pills include rifampin (Rifadin®), and to a lesser extent, amoxicillin, Bactrim®, tetracycline, minocycline, metronidazole (Flagyl®) and nitrofurantoin (Macrobid® or Macrodantin®).
By my eSignature below, I certify that I have read, fully understand and accept all terms of the foregoing information above and that all of the provided information on this form is true. Please signify your acceptance by entering the information requested in the field below. Please note that an esignature is the electronic equivalent of a hand-written signature.
Authorization and consent
General Consent to Treatment
Release of Information
Assignment of Insurance Benefits
Photography Release
Please Check the Following
By my eSignature below, I certify that I have read, fully understand and accept all terms of the foregoing information above and that all of the provided information on this form is true. Please signify your acceptance by entering the information requested in the field below. Please note that an esignature is the electronic equivalent of a hand-written signature.