New Patient Forms (Adult) Please enable JavaScript in your browser to complete this form.1Patient Type2Emergency Contact3Primary Insurance4Secondary Insurance5Dental History6Medical History7AuthorizationPatient Full Name *FirstMiddleLastGender *MaleFemaleBirth Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security NumberPhoneEmailEmployer's NameOccupationNextMarital StatusSingleMarriedDivorcedWidowedSignificant OtherEmergency Contact Name *FirstLastRelationship to Patient *Emergency Contact AddressSame as PatientEmergency Contact AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact Phone Number *This person is authorized to receive appointment and medical information concerning the patient *Yes - AuthorizeNo - Do Not AuthorizePreviousNextPrimary Insurance Company *Insurance Phone NumberGroup NumberPolicy NumberMember ID NumberPolicy Holder's NameFirstLastPolicy Holder's Relationship to PatientPolicy Holder's Birth DateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy Holder's Social Security NumberPolicy Holder's EmployerPolicy Holder's Work Phone NumberPreviousNextDoes the Patient Have Secondary Insurance?YesNoSecondary Insurance CompanySecondary Insurance Phone NumberSecondary Insurance Group NumberSecondary Insurance Policy NumberSecondary Insurance Member ID NumberSecondary Insurance Policy Holder's NameFirstLastSecondary Insurance Policy Holder's Relationship to PatientSecondary Insurance Policy Holder's Birth DateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary Insurance Policy Holder's Social Security NumberSecondary Insurance Policy Holder's EmployerSecondary Insurance Policy Holder's Work Phone NumberPreviousNextHow did you hear about our practice?AdInternet SearchFamily or FriendPhysicianOtherName of person referring (if applicable)Have your tonsils or adenoids been removed?YesNoHave you ever experienced jaw joint pain/discomfort (TMJ/TMD)?YesNoDo you have any missing or extra permanent teeth?YesNoHave you ever had an injury to (select all that apply)?TeethMouthChinDo you have speech problems?YesNoIf yes, please explainDo your gums bleed?YesNoDo you smoke?YesNoDo you like your smile?YesNoDo you currently or have you ever had any of the following habits?Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail BitingThumb/Finger SuckingChewing/Eating ProblemsPreviousNextAre you currently being treated by a physician? *YesNoPhysician NameFirstLastPhysician PhoneDate of Last VisitReason for Physician VisitDo you have any allergies/sensitivities to medications or latex?YesNoIf yes, please list allergiesAre you currently taking any prescription or over-the-counter medications?YesNoPlease list any medications taken, along with dosageHave you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?YesNoHave you had any serious illnesses or operations? If yes, please describe:Have you ever had a blood transfusion?YesNoIf yes, give approximate dates:Are you pregnant?YesNoAre you nursing?YesNoAre you taking hormonal birth control?YesNoCheck if you have or have ever had any of the following:AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal DiseasePreviousNextI understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.Patient Signature and/or Responsible Party *Today's Date *WebsiteSubmit