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.
Gender: Male Female
Whom may we thank for referring you?
Relationship to patient
Do you have secondary insurance? Yes No
Is the patient taking medication? Yes No
Is the patient allergic to any medication? Yes No
History of a major illness? Yes No
Has the patient had any operations? Yes No
Ever been involved in a serious accident? Yes No
Has seen a physician in the last 12 months aside from a check-up? Yes No
Is the patient pregnant? Yes No
If any answers above were answered yes, please explain.
Check any of the medical conditions below that the patient has had or currently has.
Please briefly explain any "Yes" responses
What concerns you most about your teeth?
Is the patient in any dental pain? Yes No
Ever experienced any unfavorable reaction to dentistry? Yes No
Has the patient ever lost or chipped a tooth? Yes No
Have there been any injuries to the face, mouth or teeth? Yes No
Is there any part of your mouth sensitive to temperature or pressure? Yes No
Do gums bleed with brushing? Yes No
Is the patient a mouth breather? Yes No
Experience jaw clicking or popping? Yes No
Aware of clenching or grinding teeth during the day? Yes No
Experience "tension" headaches? Yes No
Has the patient ever experienced chronic ringing in the ears? Yes No
Does the patient need extra help with instructions? Yes No
Is the patient sensitive or self-conscious about their teeth? Yes No
Are you aware that some appointments may be during school/business hours? Yes No
By submitting this form you certify that the above information is correct and accurate to the best of your knowledge.