New Patient Form Or can be downloaded here. Patient Name* Email* Patient Address* City* State (Initials Only)* Zip/ Postal Code* Today's Date (required) Cell Phone (Required) Home Phone Work Phone Date of Birth (Required) Date of Last Visit Date Med. History Social Security Number (No Dashes) Marital Status Is the Guarantor/ Responsible Party for billing Same as the Patient? YesNo Primary Dental Guarantor Primary Dental Guarantor Home Phone Primary Dental Guarantor Work Phone Primary Dental Guarantor Cell Phone Is there a Secondary Dental Guarantor? YesNo Secondary Dental Guarantor Secondary Dental Guarantor Home Phone Secondary Dental Guarantor Work Phone Secondary Dental Guarantor Cell Phone Physician Name Physician Phone Pharmacy Name Pharmacy Phone Sex: If female, please answer the following: Are you taking birth control pills? yesno Are you pregnant? yesno Number of weeks? Are you nursing? yesno All Please Answer the following: Do you smoke or use tobacco? yesno Height? Weight? Conditions Bad Breath yesno Bite Lips/ Cheeks yesno Bleeding Gums yesno Blisters on Mouth yesno Dry Mouth yesno Food Collection yesno Grinding Teeth yesno Pain Ear Jaw yesno Sleep Problems yesno Alzheimers Dementia yesno Artificial Joint yesno Alcohol/ Drug Abuse yesno Anemia yesno Arthritis yesno Asthma Copd yesno Bacterial Endocarditis yesno Blood Thinners yesno Back Problems yesno Cancer yesno Chemotherapy yesno Chest Pain yesno Circulatory Problems yesno Congenital Heart yesno Diabetic yesno Dialysis yesno Emphysema yesno Epilepsy yesno Fainting Spells yesno Heart Problem yesno Heart Artificial Valve yesno HIV Aids yesno Hepatitis yesno Herpes Shingles yesno High Blood Pressure yesno Immune Suppression yesno Kidney Disease yesno Low Blood Pressure yesno Nervous Anxious yesno Osteoporosis yesno Premed yesno Pacemaker yesno Psychiatric Problems yesno Rheumatic Fever yesno Shunts/Stints yesno Sinus Problems yesno Sjogren's Syndrome yesno Stroke yesno Surgeries yesno Thyroid Problems yesno Tuberculosis yesno Allergies Aspirin yesno Codeine yesno Dental Anesthetics yesno Erythromycin yesno Jewelry yesno Latex yesno Metals yesno Penicillin yesno Tetracycline yesno Other Allergies Medications you are taking. Is there any disease, condition or problem that you think this office should know about that is not covered above? yesno If yes, please describe below.. Patient Signature Date
