Name *
Name
First & Middle (no comma)
XXX-XX-XXXX
Date of Birth *
Date of Birth
How did you hear about us? *
Cell Phone
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
Significant Others' Phone
Significant Others' Phone
Name, Relationship, Phone
Employer's Phone
Employer's Phone
Insurance
Policy Holder Name
Policy Holder Name
Policy Holder DOB
Policy Holder DOB
XXX-XX-XXXX
Insurance Co, Policy Holder, Holder DOB, ID #, Group #
Reason for your visit
Last Dental Visit Date
Last Dental Visit Date
If YES - Please have them emailed to [email protected]
How often do you Brush?
How often do you Floss
What type of toothbrush do you currently use?
Current Issues
Check all that apply
Any other oral health issues we should be aware of?
Valves, Rods, Pins
Women
Are you...
HEALTH HISTORY
(You're almost finished)
Current/Past health issues:
Check all that apply
Are you allergic to any of the following?
Check all that apply
It is the responsibility of the patient to provide 24 hours notice of cancellation or re-scheduling of their appointment. Canceling/ re-scheduling your appointment with less than 24 hours will result in a fee of $45/hour scheduled that is missed. Please note that the missed appointment fee is not covered by any insurance provider and is the patients responsibility to pay. PLEASE TYPE INITIALS BELOW AS YOUR ELECTRONIC SIGNATURE