New Patient Form
General Information
Medical History
Insurance Information
Please enter your insurance information
Personal information
Gender
Contact Information
Medication
Are you currently under physician care?
Are you currently taking any medication?
Previous dentist or dental office
History
How do you feel about dental treatment?
Have you seen a dentist before?
Are you happy with the appearance of your teeth?
Have you avoided regular dental care?
Would you like your teeth to be whiter?
Would you like your teeth to be straighter?
Do you have, or have you ever had any of the following dental conditions? Please check all that apply
Insurance
Will you be using insurance? *
Authorizations and Acknowledgements
I certify that I have read and understand the above. I acknowledge that my questions regarding this form have been answered to my satisfaction. I will not hold my dentist or any other member of the office staff responsible for errors or omissions that I may have made in the completion of this form. I acknowledge that if I make omissions or false statements, my health may be put at risk.
