New Patient Form Patient InformationName *Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\’IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEmail *Sex *MaleFemaleBirthdate *Patient SS# Marital Status *MarriedWidowedSingleSeparatedDivorcedPartneredMinorPatient Employer Spouse's InformationSpouse's Name Spouse's Birthdate Spouse's SS# Spouse's Employer Phone NumbersHow would you like to receive appointment reminders? *Home PhoneWork PhoneTextEmailHome Work Cell Spouse's Work Best times and place to reach you Whom may we thank for referring you? Dental InsuranceWho is responsible for this account? Relationship to patient Insurance Co. Group # Is patient covered by additional insurance? YesNoSubscriber’s Name Birthdate SS# Relationship to Patient Secondary Insurance Name of Insured Group # Dental HistoryReason 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 YesNoBleeding Gums YesNoCigarette, pipe, or cigar smoking YesNoDry mouth YesNoSensitivity when biting YesNoFood collection between teeth YesNoGrinding teeth YesNoJaw Pain YesNoLoose teeth or broken fillings YesNoOrthodontic treatment YesNoPeriodontal treatment YesNoSensitivity to cold YesNoSensitivity to heat YesNoSensitivity to sweets YesNoHow often do you floss? How often do you brush? Health HistoryPhysician’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 YesNoArtificial Heart Valves YesNoArtificial Joints YesNoAsthma YesNoBleeding abnormally, with extractions or surgery YesNoBlood Disease YesNoCancer YesNoCongenital Heart Lesions YesYesDiabetes YesNoEmphysema YesNoEpilepsy YesNoHeart Murmur YesNoHeart Problems YesNoHepatitis YesNoHerpes YesNoHigh Blood Pressure YesNoKidney Disease YesNoLiver Disease YesNoLow Blood Pressure YesNoMitral Valve Prolapse YesNoPacemaker/Defibrillator YesNoRespiratory Disease YesNoStroke YesNoTuberculosis YesNoWomenAre you pregnant? YesNoDue Date If you answered yes. What is your due date?Taking birth control pills? YesNoAre you nursing? YesNoMedications List any medications you are currently taking and the correlating diagnosis:Pharmacy Name Allergies AsprinBarbituatesCodeineIodineLatexLocal AnesthesiaPenicillinSulfaOther Allergies Please list other allergies VerificationPlease enter any two digits *Example: 12This box is for spam protection – please leave it blank:
