(985) 785-0123
Home
About Us
COVID-19
Services
Contact
New Patient Forms
(985) 785-0123
Email Us!
Home
About Us
COVID-19
Services
Contact
New Patient Forms
New Patient Forms
Home
New Patient Forms
Patient Information
Name
*
Address
*
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
Email
*
Sex
*
Male
Female
Birthdate
*
Patient SS#
Marital Status
*
Married
Widowed
Single
Separated
Divorced
Partnered
Minor
Patient Employer
Spouse's Information
Spouse's Name
Spouse's Birthdate
Spouse's SS#
Spouse's Employer
Phone Numbers
How would you like to receive appointment reminders?
*
Home Phone
Work Phone
Text
Email
Home
Work
Cell
Spouse's Work
Best times and place to reach you
Whom may we thank for referring you?
Dental Insurance
Who is responsible for this account?
Relationship to patient
Insurance Co.
Group #
Is patient covered by additional insurance?
Yes
No
Subscriber’s Name
Birthdate
SS#
Relationship to Patient
Secondary Insurance
Name of Insured
Group #
Dental History
Reason for today’s visit
Former Dentist
City/State
Date of last dental visit
Date of last dental X-rays
Place a mark on “yes” or “no” to indicate if you have had any of the following:
Bad Breath
Yes
No
Bleeding Gums
Yes
No
Cigarette, pipe, or cigar smoking
Yes
No
Dry mouth
Yes
No
Sensitivity when biting
Yes
No
Food collection between teeth
Yes
No
Grinding teeth
Yes
No
Jaw Pain
Yes
No
Loose teeth or broken fillings
Yes
No
Orthodontic treatment
Yes
No
Periodontal treatment
Yes
No
Sensitivity to cold
Yes
No
Sensitivity to heat
Yes
No
Sensitivity to sweets
Yes
No
How often do you floss?
How often do you brush?
Health History
Physician’s Name
Date of last visit
Place a mark on “yes” or “no” to indicate if you have had any of the following:
AIDS/HIV
Yes
No
Artificial Heart Valves
Yes
No
Artificial Joints
Yes
No
Asthma
Yes
No
Bleeding abnormally, with extractions or surgery
Yes
No
Blood Disease
Yes
No
Cancer
Yes
No
Congenital Heart Lesions
Yes
Yes
Diabetes
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Heart Murmur
Yes
No
Heart Problems
Yes
No
Hepatitis
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Mitral Valve Prolapse
Yes
No
Pacemaker/Defibrillator
Yes
No
Respiratory Disease
Yes
No
Stroke
Yes
No
Tuberculosis
Yes
No
Women
Are you pregnant?
Yes
No
Due Date
If you answered yes. What is your due date?
Taking birth control pills?
Yes
No
Are you nursing?
Yes
No
Medications
List any medications you are currently taking and the correlating diagnosis:
Pharmacy Name
Allergies
Asprin
Barbituates
Codeine
Iodine
Latex
Local Anesthesia
Penicillin
Sulfa
Other Allergies
Please list other allergies
Verification
Please enter any two digits
*
Example: 12
This box is for spam protection - <strong>please leave it blank</strong>:
