New Patient Dental Information
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
First Name
Last Name
Date of Birth
DENTAL INFORMATION
Do your gums bleed while brushing or flossing?
Yes
No
Do you bite your lips or cheeks frequently?
Yes
No
Have you ever had Orthodontic (braces) Treatments?
Yes
No
Do you have Headaches or Migraines?
Yes
No
Are your teeth sensitive to cold, hot, sweets or pressure?
Yes
No
Have you had any difficult extractions in the past?
Yes
No
Do you feel pain to any of your teeth?
Yes
No
Ever worn a bite plate or other appliance?
Yes
No
Do you have any sores or lumps in or near your mouth?
Yes
No
Have you ever had difficulty opening or closing jaw?
Yes
No
Have you ever had a head, neck or jaw injury?
Yes
No
Have you had any pain in your jaw area?
Yes
No
Do you have any loose teeth or have they ever shifted?
Yes
No
Have you ever had Periodontal Treatment (gums)?
Yes
No
Does food frequently get caught in your teeth?
Yes
No
Please give a brief description of your Oral Hygiene habits:
If you have a current dental problem, please describe:
Please enter your previous Dentist name and Location:
Do you have any other concerns about having Dental Treatment?
Yes
No
If so, please explain:
Do you ever feel nervous about visiting the Dentist?
Yes
No
if so, please explain:
Are you happy with the appearance of your teeth?
Yes
No
If no, please explain:
Date or your last Dental X-Ray:
Date of your last teeth cleaning:
What can we do to make you smile? Check all that apply, and we'll get back to you with more information about your inquiry:
Veneers
Gummy Smile
White Fillings
Oral Conscious Sedation
Total Smile Makeovers
Replace Metal Fillings
Neuromuscular Dentistry
Replace Missing Teeth
Correct Misaligned Teeth
Instant Orthodontics
Cosmetic Dentures
Sleep Apnea/Snoring
Broken/Cracked Teeth
Dental Implants
Eliminate Gaps
Invisalign teeth Straightening
One Hour In-Office Whitening
Rejuvenate Worn /Stained Teeth
CHILDREN ONLY
Please list any medical conditions or illnesses the child has recently had. This can include Measles, Strep Throat, Tonsillitis.
Health Care Info
Health Card Number
Drivers License
INSURANCE INFORMATION
Your coverage details. Please review them and make any necessary adjustments.
Primary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
Secondary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes