We provide the opportunity for you to print and complete our new patient forms before you arrive at our office. Please use the button below to download the forms. You may also fill out our online form instead: Name* First Last Email* Home Phone*Cell PhoneBirthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical HistoryHave you ever had any of the following diseases or medical problems? Abnormal Bleeding Alcohol / Drug Abuse Anemia Arthritis Artificial Bones / Joints / Valves Asthma Blood Transfusion Cancer / Chemotherapy Colitis Congenital Heart Defect Diabetes Difficulty Breathing Emphysema Epilepsy Fainting Spells Frequent Headaches Glaucoma Hay Fever Heart Attack Heart Murmur Heart Surgery Hemophilia Hepatitis Herpes / Fever Blisters High Blood Pressure HIV+ / AIDS Hospitalized for Any Reason Kidney Problems Liver Disease Low Blood Pressure Mitral Valve Prolapse Pacemaker Psychiatric Problems Radiation Treatment Rheumatic / Scarlet Fever Seizures Shingles Sickle Cell Disease / Traits Sinus Problems Stroke Thyroid Problems Tuberculosis (TB) Ulcers Venereal Disease Please list any serious medical condition(s) that you have ever had:Are you allergic to any of the following? Aspirin Codeine Dental Anesthetics Erythromycin Jewelry Latex Metals Penicillin Tetracycline Please list any other drugs/materials that you are allergic to:Your current physical health is:GoodFairPoorAre you taking any prescription / over-the-counter or herbal supplement drugs?YesNoPlease list each one:Have you ever taken Fosamax, or any other bisphosphonate?YesNoHave you ever taken Phen-fen?YesNoFor Women: Are you using a prescribed method of birth control?YesNoAre you pregnant?YesNoWeek #:Are you nursing?YesNoDo you require antibiotics before dental treatment?YesNoAre you currently in pain?YesNoDo your gums ever bleed?YesNoHave you ever had a serious / difficult problem associated with any previous dental work?YesNoDo you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?YesNoYour current dental health is:GoodFairPoorDo you like your smile?YesNoWould you like whiter teeth?YesNoWould you like fresher breath?YesNoHow many times a week do you floss?How many times a day do you brush?Which type of bristles?SoftMediumHardDo you smoke or use tobacco in any form?YesNoInsurance CoverageDental CoverageYesNoInsurance Company NameInsurance Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Insurance Company PhoneGroup # (Plan, Local, or Policy #):Insured's Name First Last RelationInsured's BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insured's ID #:Insured's Employer:If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. Our office is HIPAA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.Signature*DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920