New Patient Forms Packet
Please print, complete, and bring these forms to your first visit, or arrive 15 minutes early to complete them in our office. If the patient is a minor, a parent or legal guardian must complete and sign every form on the patient's behalf.
Included in this packet: 1) Patient Information · 2) Health History · 3) Dental History · 4) Coordination of Benefits (complete only if you have more than one dental plan) · 5) Minor Patient Information & Care-Taker Authorization (complete only if the patient is a minor)
1. Patient Information
Patient Name (First, MI, Last)
Address (Street, City, State, ZIP)
Driver's License # / State (optional)
By providing your email, you agree to receive: ☐ Appointment reminders ☐ Practice newsletter
Preferred contact method: ☐ Home ☐ Mobile ☐ Email
Marital status: ☐ Married ☐ Single ☐ Divorced ☐ Widowed
Emergency Contact & Phone
Is the patient a minor? ☐ Yes ☐ No (if yes, a parent/guardian also completes Section 5)
Dental Benefit Plan Information
Primary Plan Name & Phone
Name of Insured / DOB / ID / Policy #
Secondary Plan Name & Phone (if any)
Name of Insured / DOB / ID / Policy #
How did you hear about us? ☐ Existing patient (name: ______) ☐ Advertisement ☐ Our website ☐ Other
Financial & Scheduling Policy
Payment is due at the time services are rendered. We accept cash, check, and Visa, Mastercard, American Express, and Discover, as well as financing through CareCredit, subject to credit approval. If you have a dental benefit plan, we are happy to help you understand and maximize your coverage; you remain responsible for any portion not covered by your plan.
We reserve dedicated time for every appointment. To reschedule or cancel, we require at least 24 hours' notice. A $75 fee applies for missed appointments or cancellations without adequate notice.
☐ I authorize this dental team to perform necessary dental services I have consented to during diagnosis and treatment, and I agree to the financial and scheduling terms above. ☐ I authorize release of information necessary to process my dental benefit claims and payment directly to this office. ☐ I acknowledge this practice's Notice of Privacy Practices has been made available to me.
Signature of Patient (or Parent/Guardian if a minor)
2. Confidential Health History
☐ Yes ☐ No — Is your general health good?
☐ Yes ☐ No — Any hospitalization, ER visit, or serious illness in the last 3 years?
☐ Yes ☐ No — Are you currently under a physician's care?
☐ Yes ☐ No — Are you in pain now?
☐ Yes ☐ No — Have you ever been pre-medicated before dental treatment?
☐ Yes ☐ No — Do you use tobacco, alcohol, or recreational drugs?
If you answered "Yes" to any question above, please explain:
Do you have or have you had any of the following? (check all that apply)
☐ Heart disease / heart attack
☐ High blood pressure
☐ Artificial joint or heart valve
☐ Diabetes
☐ Asthma or lung disease
☐ Kidney or liver disease
☐ Cancer, chemotherapy, or radiation
☐ Seizures or neurological condition
☐ Bleeding or clotting disorder
☐ Hepatitis, TB, or HIV/AIDS
☐ Anxiety, depression, or emotional condition
☐ Bisphosphonate use (e.g., Fosamax)
☐ Pregnant or nursing (if applicable) — if pregnant, how many months?
☐ Other condition not listed:
Are you allergic to any of the following?
☐ Penicillin / antibiotics
☐ Local anesthetic (Novocain)
☐ Latex
☐ Aspirin / NSAIDs
☐ Codeine / opioids
☐ Metal
☐ Food or other:
Please list all medications you currently take
I certify that I have read and understand this form and have answered every question completely and accurately to the best of my knowledge. I will inform my dentist of any change in my health or medication. I authorize the dentist to contact my physician if needed.
Signature of Patient (or Parent/Guardian if a minor)
3. Dental History
What are your goals in coming to our practice today?
Date of Last Exam / Cleaning / X-rays
☐ Yes ☐ No — Are you experiencing any pain now?
☐ Yes ☐ No — Have you had problems with prior dental treatment?
☐ Yes ☐ No — Have you been anxious about having dental treatment?
What concerns do you currently have? (check all that apply)
☐ Jaw joint pain
☐ Clenching or grinding
☐ Discolored teeth
☐ Crowding / crooked teeth
☐ Missing teeth
☐ Spaces between teeth
☐ Loose tooth/teeth
☐ Sensitivity to hot/cold
☐ Food caught between teeth
☐ Difficulty chewing
☐ Bad breath
☐ Uncomfortable bite
☐ Old fillings or crowns
☐ Unhappy with tooth shape/color
☐ Other:
Interested in learning more about? (check all that apply)
☐ Teeth whitening
☐ Veneers / bonding
☐ Invisalign (clear aligners)
☐ At-home oral hygiene care
☐ Periodontal (gum) treatment
☐ Other:
4. Coordination of Benefits Questionnaire
Complete this section only if you are covered by more than one dental or medical plan. It helps us determine which plan pays first.
☐ Yes ☐ No — Are you covered by more than one dental plan?
Which coverage is primary (covers you other than as a dependent)?
If a dependent child is covered by both parents' plans, birthdates of each parent:
Note: the plan of the parent with the earlier birthday in the calendar year is typically primary for a child covered by both parents.
If parents are separated or divorced, which parent has custody? ☐ Mother ☐ Father ☐ Other
☐ Yes ☐ No — Do you have coverage under a current employer as well as a former employer?
Note: coverage through your current employer is typically primary over a former employer's plan.
Who is your medical insurer (some medical plans cover certain dental procedures)?
5. Minor Patient Information & Care-Taker Authorization
Complete this section only if the patient is a minor. A parent or legal guardian must complete and sign on the patient's behalf.
Patient's primary residency: ☐ Both parents ☐ Mother ☐ Father ☐ Stepparent ☐ Shared custody ☐ Guardian
Parent / Legal Guardian Information
Name of Responsible Party
Address (if different from patient)
☐ Same dental & medical benefit plan information as listed in Section 1 ☐ Different — see attached
Authorization for a Care-Taker (Non-Legal Guardian) to Accompany a Minor to Appointments — Optional
I authorize the named care-taker to bring my child to scheduled appointments for treatment previously consented to by a legal guardian. This authorization does not permit the care-taker to consent to new treatment on my child's behalf — only a legal guardian may do so. If new treatment consent is needed during a visit, our office will contact the legal guardian before proceeding. This authorization remains in effect until we are notified otherwise.
I certify that the information above is correct to the best of my knowledge, and as the parent or legal guardian, I authorize this dental team to perform necessary dental services for my child that I have consented to during diagnosis and treatment.
Signature of Parent / Legal Guardian