Welcome

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care.
Please fill out both our new patient information form and our new patient medical form on-line
or arrive 15 minutes prior to your first appointment time. 
 

PATIENT MEDICAL HISTORY - CONFIDENTIAL

Name *
Name
Office Phone *
Office Phone
Medical History *
Please place a check mark beside each question you answer with "yes".
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
Are you taking any medications including non-prescriptions? *
Are you allergic to or have you had any reactions to the following? *
Please check all that apply.
Women Only
Do you have or have you had any of the following? *
Please check all that apply.
Name of Previous Dentist and Location
Date of Last Exam *
Date of Last Exam
Please check all that you would answer yes. *
Have you ever experienced any of the following problems in your jaw? *
Please check all that apply
Do you wear dentures or partials? *
By typing my name below, I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and /or health practicioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill or services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.