New patient form

Relative or Friend not living with you

Primary Insurance

Secondary Insurance

Do you have personal physician?
Your current physical health is:
Are you currently under care of a physician?
Do you smoke or use tobacco in any other form:
Have you had any metal rods, pins or implants?
Are you taking any prescription / over-the-couter drugs?
Have you ever taken Fosamax, or any other bisphosphonate?
Have you ever taken Phen-fen?

For women:

Are you using prescribed method of birth control?
Are you pregnant?
Are you nursing?
Have you ever had any of the following diseases or medical problems?
Are you allergic to any of the following
Are you currently in pain?
Do you require antibiotics before dental treatment?
Your current dental health is:
Have you ever had a serious/difficult problem associated with any previous dental work?
Do you floss daily?
Brush daily?
Type of bristles on you toothbrush?
Have you ever had gum treatment?
Do your gums ever bleed?
Ever itch?
Have you ever had periodontal disease?
Do you now or have you ever experienced pain / discomfort in you jaw joint (TMU /TMD)?
Do you have any loose teeth?
Do you still have wisdom teeth?
Would you like fresher breath?
Whiter teeth?
Are you happy with the way your smile looks?
I 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 confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.

Office hours

  • Monday: 9:00 - 6:00
  • Tuesday: 9:00 - 6:00
  • Wednesday: 9:00 - 6:00
  • Thursday: 9:00 - 6:00
  • Friday: by appointment
  • Saturady: & Sunday closed