• New Patient Form

    New Patient Form

  • Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Person Responsible For Account

  • Format: (000) 000-0000.

  • Emergency Contact

    Not living with you
  • Format: (000) 000-0000.

  • Medical History

  • Has the patient been treated for orthodontics before?*
  • Have any relatives had a protruding jaw or needed jaw surgery?*
  • Have there been any injuries to the face, mouth, teeth, or chin?*
  • Has the patient ever had any pain/tenderness in his/her jaw joint?*
  • Has the patient ever had periodontal (gum) treatment?*
  • If patient is a minor, has puberty begun?*
  • Do you pre-medicate before dental visits?*
  • Has the patient ever taken osteoporosis medications or weight loss drugs?*

  • Has the patient ever had any of the following?

  • Abnormal Bleeding*
  • ADD/ADHD*
  • Allergies*
  • Allergy to Medications*
  • Arthritis*
  • Artificial Heart valves or joints*
  • Asthma*
  • Back or neck problems*
  • Breathing problems*
  • Cancer*
  • Diabetes*
  • Epilepsy*
  • Headaches/Migraines*
  • Hearing Impairment*
  • Heart murmur/defect*
  • Heart problems*
  • Hemophilia*
  • Hepatitis*
  • Herpes (any type)*
  • High blood pressure*
  • HIV or AIDS*
  • Kidney/Liver Problems*
  • Psychological Counseling*
  • Ringing in ears*
  • Rheumatic/Scarlet Fever*
  • Seizures*
  • Sinus problems*
  • Sleep Apnea*
  • Speech problems*
  • Swallowing problems*
  • Tonsils/Adenoids removed*
  • Tuberculosis*
  • Ulcers*
  • Any Handicaps/ Disabilities*
  • Any operations*

  • Does/Has the patient have/had any of the following habits?

  • Frequent gum chewing*
  • Chew/Smoke Tobacco*
  • Clenching/Grinding Teeth*
  • Lip Sucking/Biting*
  • Mouth Breather*
  • Nail Biting*
  • Thumb/Finger Sucking*
  • Tongue Thrust*

  • Signatures

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

  • Should be Empty: