SSN

XXX-XX-XXXX

Street Address

City, State, Zip

Other / Name of Current Patient

Email Address

Status

Significant Others' Name

Whom may we contact in an Emergency?

Name, Relationship, Phone

Employer

Insurance

Insurance Company Name

Policy Holder's Employer

Policy Holder SSN

XXX-XX-XXXX

Group #

ID #

Do you have secondary insurance?

Tell us more about it

Insurance Co, Policy Holder, Holder DOB, ID #, Group #

(other) Reason(s) for our visit

Former Dentist

Have you had X-rays in the last 6 months?

If YES - Please have them emailed to [email protected]

Current Issues (other)

Any other oral health issues we should be aware of?

Do you have a personal physician?

Physician's Name & Phone #

Current Health

Do you have implants?

Valves, Rods, Pins

Please list

Are you taking any medications?

If YES, what/when?

What would you like to change most about the appearance of your smile?

Do you have any missing or chipped teeth?

Do you have any alignment/spacing/crowding you would like to review during your visit?

Do you have any previous dental treatment or experiences that you would like us to know about?

HEALTH HISTORY

(You're almost finished)

Other Health Concerns

Any other allergies?

Anything else we should know?

Cancellation Policy

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