Are you a New Patient or a Current Patient Updating your Information?
New Patient Establishing Care
Current Patient Updating Information
Patient Name
*
First Name
Last Name
Date of Birth (xx/xx/xxxx)
Patient Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Patient Email Address
*
Patient Home Phone
(###)
###
####
Patient Cellular Phone
(###)
###
####
Patient Work Phone
(###)
###
####
Patient's Employer and Job Title (If Applicable)
When and where is the best time and place to contact you?
Patient's Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Spouse Name
First Name
Last Name
Spouse Employer and Job Title (If Applicable)
Who can we thank for referring you?
Previous Dentist and Approximate Date of Last Visit
Person Responsible for Account
Primary Insurance Name, Address and Phone Number
Please enter details below
Primary Insurance Group/ID Numbers
Secondary Insurance Name, Address and Phone Number
Please enter details below
Secondary Insurance Group/ID Numbers
In the event of an emergency, is there someone who lives near that we should contact?
Emergency Contact Phone
(###)
###
####
Primary Care Physician Name/Approximate Date of Last Visit
Please List ALL Medications Currently Taking and WHY...
Have you ever had any of the following medical issues?
Please Check all that apply
Please Give Details of Conditions Marked Above...
If you have been hospitalized, please describe when and for what reason...
Allergies?
Please Check all that you are allergic to...
Other Allergies to Medications? Please List Below
Why are you seeking dental treatment today?
Are you in any pain?
Yes! Severe Pain
Yes, Moderate Pain
Yes, Occasional, Intermittent Pain
No Pain
Rate your dental Health
Excellent
Good
Fair
Poor
Do you like your smile?
Yes
No, and I'd love to discuss options for improving it
No, but I'm fine with it the way it is.
Do your gums bleed?
Yes, any time I brush or floss
Occasionally
No
Tobacco Use
Chewing Tobacco Only
Smoking Only
Chewing Tobacco and Smoking
Have you ever had treatment for periodontal disease?
Yes, previous Root Planning and Periodontal Scaling
Yes, currently on Periodontal Maintenance
No, I usually just have Routine Cleanings
How many times a DAY do you brush?
Three or more times a day
Twice a day
Once per day
Rarely
How many times a WEEK do you floss?
Daily
3-5 times per week
1-2 times per week
Only before I come to the dentist
Never, though I hate to admit it :)
Type of Toothbrush used?
Hard Bristles
Medium Bristles
Soft Bristles
