Welcome!

New Patient Intake Form

This is a lengthy form, so please make sure you have enough time to fill out each section and submit.

Required fields and those with errors are marked with a red border.

To navigate this multi-part form, use the green buttons below each section, not your browser or device buttons.
To navigate this multi-part form, use the green buttons below, not your device or browser buttons.

When you're ready to start, click "Begin" below.

Step 1: Name and Address

All fields in this step are required

Step 2: Additional Information

Step 3: Insurance Information

Step 4: Medical Information (Pt 1)

Yes
No

2. Are you currently taking any medications or vitamins?

Yes
No
Yes
No

4. Are you allergic to or ever had a reaction to any of the following?

Penicillin

Codeine

Local Anesthetic ("freezing")

Aspirin (ASA)

Sulfa Drugs

Yes
No

Step 4: Medical Information (Pt 2)

6. Do you bleed more or longer than mormal after a cut, bruise, surgery or previous tooth removal?

Yes
No

7. Have you ever had a serious illness or operation?

Yes
No

8. Do you currently have or ever had any of the following conditions?

Heart Trouble or Stroke

Heart Murmur

Thyroid Disorder

Rheumatic Fever

Breathing Problems

Arthritis

HIV Positive

Tumors or Cancer

High/Low Blood Pressure

Hepatitis

Liver Disease

Kidney Disease

Mental Illness

Diabetes

Tuberculoses

Epilepsy or Seizure

Blood Disorders

Hormonal Disorder

Step 4: Medical Information (Pt 3)

9. Women: Are you pregnant?

Yes
No

10. Is there anything else we should know about your health?

Yes
No

11. What dental condition(s) concern you at present?

12. What is the name and contact info for your previous dentist?

13. Were X-rays taken at your last dental visit?

Yes
No

Step 5: Now, About Your Teeth... (Pt 1)

14. What do you want for your teeth over the next 20 years?

15. Have you noticed any signs of the following:

Bleeding Gums

Drifting of Teeth

Gum Ache

Receding Gums

Loose Teeth

16. Do you have any clicking, popping or pain in your jaw joint?

Yes
No

17. Are you aware of clenching or grinding your teeth?

Yes
No

Step 5: Now, About Your Teeth... (Pt 2)

18. Do you have any missing teeth that you feel should be replaced?

Yes
No

19. Would you like to improve the appearance of your teeth?

Yes
No
Yes
No

21. Have you had any complications or difficulty with previous dental treatment?

Yes
No

22. How do you rate yourself as a dental patient?

Calm

Slightly Nervous

Very Anxious

Step 6: Ready to Send?

How did you hear about us?

Website

Google Search

Facebook

Print Advertising

Walk By

Personal Referral

Disclaimer

By clicking "SEND", I hereby certify that the Medical and Dental Histories provided are accurate and complete to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic or any drugs as indicated and I will assume responsibility for fees associated with those procedures.

Send a copy to me, too?

Answer this skill testing questions to make sure you are human...

Thank you!

Your intake form has been submitted successfully.

To return to our website, click the link at the top of the page.

Oh-oh...

Something has gone wrong!

Your Intake Form could not be sent. Please try again later. If problems continue, please let us know.

To return to our website, click the link at the top of the page.