This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). This is a secure form; the information that you enter here will be seen only by the staff of our practice.

Directions: Fill out all applicable fields and submit the form. We will contact you if there are any concerns or errors with your submission.

Patient Information


Party Responsible for Payment

Dental Insurance Information

Do you have secondary insurance?   

Emergency Contact Information


Patient Medical History


Is the patient taking medication?    

Is the patient allergic to any medication?  

History of a major illness? 

Has the patient had any operations?  

Ever been involved in a serious accident?  

Has seen a physician in the last 12 months aside from a check-up?   

Is the patient pregnant?  

Check any of the medical conditions below that the patient has had or currently has.


Patient Dental History


Is the patient in any dental pain? 

Ever experienced any unfavorable reaction to dentistry?  

Has the patient ever lost or chipped a tooth?  

Have there been any injuries to the face, mouth or teeth?  

Is there any part of your mouth sensitive to temperature or pressure?  

Do gums bleed with brushing?  

Is the patient a mouth breather?  

Experience jaw clicking or popping?  

Aware of clenching or grinding teeth during the day?  

Experience "tension" headaches?  

Has the patient ever experienced chronic ringing in the ears?   No

Does the patient need extra help with instructions?   

Is the patient sensitive or self-conscious about their teeth?  

Are you aware that some appointments may be during school/business hours?  

By submitting this form you certify that the above information is correct and accurate to the best of your knowledge.