New Patient Chart
Your personal details. Please review them and make any necessary adjustments.
Unspecified/Prefer Not To Answer
Date of Birth
Postal /Zip Code
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Phone #
Person responsible for this account:
II. Medical Information (Confidential)
Are you currently under the care of a physician?
If so, please speify
Have you ever had serious illness requiring hospitalization or extensive medical care?
Do you use any prescription or non prescription drugs regularly (including herbals/vitamins)?
Do you have any allergies to
Sleeping Pills (Barbiturates)
If you have any other allergies not listed above, please list
Have you been warned against taking any drug or medication?
Do you bruise easily or bleed abnormally?
Do you require any pre-mediation (antibiotics) for dental treatment?
Have you ever had any organ transplants or medical implants?
Do you ever experience shortness of breath or chest pain when taking a walk or climbing stairs?
Do you have AIDS or have tested positive for H.I.V?
Do you have any of the following? Please check any that apply.
Heart murmur or mitral valve prolapse
Epilepsy or Seizures
Joint Replacement (hip,knee etc)
Lung Disease (i.e. Asthsma)
Mental or Nervous Disorders
High/Low Blood Pressure
Low Blood Pressure
Arthritis or Rheumatism
Scarlet or Rheumatic Fever
Have you had any injury, surgery or radiation therapy to your face, jaw or neck?
Does your family have a history of head, neck and/or oral cancer?
Do you smoke?
If so, how long have you been smoking?
How much do you smoke in one day?
Do you have any diseases, conditions or problem that you think the doctor should know about?
If so, specify
Are you pregnant or suspect you might be?
If so, how far along are you (weeks)?
Are you nursing?
Are you taking Birth Control?
III. Dental History
Reason for visiting our office
If other, specify
Are you presently having dental pain?
If yes, specify
How frequently do you see your dentist?
If other, specify
Last dental visit
How often do you brush your teeth?
Do your gums bleed easily?
Are your teeth sensitive to any of the following?
Do you feel you have bad breath at times?
Do you have pain in your jaw joints or suffer from migraine headaches?
Does any part of your mouth hurt when clenched?
Have you had any of the following?
Have you ever experienced any growths or sore spots in your mouth?
If so, where?
Are you dissatisfied with the appearane of your teeth?
If you could, what features of your smile would you like to change?
Insurance companies now only allow for 'functionally acceptable work', whereas, in the past their coverage was for 'quality work'. It is our desire to provide our patients with the highest quality work within their financial capabilities and desires. What is important to you? (check one)
The highest quality dentistry available
The most economical treatment plan
Dentistry limited to insurance coverage
A combination of the above, please explain
OFFICE POLICY: Your appointment time will be reserved for you. If you have unable to keep the appointment we will require 24 hours notice, otherwise it may be necessary to charge for the time lost. Patients not showing for confirmed appointments may be charged accordingly.
PATIENT RELEASE: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. i authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understant that consultation with my medial doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental servies provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.