We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible.

Thank You!


Patient Information





Spouse / Partner Information

Marital Status

Person(s) OK to release appointment or medically related information to concerning you:

Insurance Information




Dental History

How did you hear about our Practice?
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits (check all that apply)





Medical History

Are you currently being treated by a physician?
Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Have you had any serious illnesses or operations? If yes, describe:
Have you ever had a blood transfusion?
Check if you have or have ever had any of the following:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.


Please enter the verification codes listed below to continue with submitting your form.