New Patient

Age:

City:

Postal Code:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

How do you prefer to receive appointment reminders? TextEmailPhone Call

Occupation:

Name of Employer:

Emergency Contact:

Medical Doctor:

Do you have a dental insurance? YesNo

Insurance Company Name:

Policy Number:

Certificate Number:

Relationship to Subscriber SelfSpouseChildOther

How do you hear about our practice? OnlineAdvertisementWalk inLive / Work in neighborhoodReferral

Name of the Person who referred you:

Patient Medical Information

Are you being treated for any medical conditions at the present time or have been treated within the least year? YesNoNot Sure

If so, why?

When was your last medical check-up?

Have there been any changes in your general health in the last year?YesNoNot Sure

If yes, please explain

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?YesNoNot Sure

If yes, please list

Do you have any allergies? If you answered yes, please list using the categories below YesNoNot Sure

Medications

Latex/Rubber Products

Other (e.g. Hayfever. Foods)

Have you ever had an uncommon or adverse reaction to any medicines or injections?YesNoNot Sure

If yes, explain

Do you have or have you ever had asthma? YesNoNot Sure

Do you have or have you ever had any heart or blood pressure problems? YesNoNot Sure

Do you have or have ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis) a heart condition from birth (i.e. congenital heart disease) or a heart transplant? YesNoNot Sure

Have you ever had hepatitis, jaundice or liver disease? YesNoNot Sure

Which type of hepatitis?

Do you have a prosthetic or an artificial joint? YesNoNot Sure

If yes, please explain

Do you have a bleeding problem or a bleeding disorder? YesNoNot Sure

If yes please explain

Have you ever been hospitalized for any liness or operations? YesNoNot Sure

If yes, please explain

Do you have any conditions or therapies that could affect your immune system. e.g. leukemia, AIDS, HIV infection, radiotherapy chemotherapy?YesNoNot Sure

Do you nave or have you ever had any of the following?

AlzheimersAnginaAnemiaArthnusBlood TransfusionCancerChest PainCold SoresDiabetes Type 1Diabetes Type 2Digestive Disorders/ Acid RefluxDrug/Alcohol DependencyEmphysemaEpilepsy or SeizuresFibromyalgiaHead Neck InjuryHeart AttackHeart MurmurHigh/Low blood PressureHodgkins DiseaseHypo / HyperglycemiaKidney Disease Lung DiseaseLupusMigraineMitral Valve ProlapseOsteoporosis MedicationsMental Disease/Anxiety DisorderPacemakerParkinsons DiseaseRadrauon/ChemotherapyRheumatic FeverSexually Transmitted InfectionShortness of Breath SleepApneaSteroid TherapyStomach UlcersStrokeThrushThyroid DisorderTMJ DisorderTuberculosis

Are there any conditions or disease not listed above that you have or have had? YesNoNot Sure

If yes, please list

Are there any diseases or medical problems that run in your family? (e.g. diabetes. cancer or heart disease) YesNoNot Sure

If yes, please explain

Do you smoke or chew tobacco products? YesNoNot Sure

Are you nervous during dental treatment? YesNoNot Sure

If yes, explain why

Patient Dental History

What is your present dental problem?

When was your last dental visit?

When did you last have dental x-rays taken?

Have you been seeing dentist regularly?YesNoNot Sure

Have you ever been advised to take antibiotics before dental appointments? YesNoNot Sure

Do your gums bleed when you brush? YesNoNot Sure

Do you have any pain when you chew? YesNoNot Sure

Do you feel that you have bad breath? YesNoNot Sure

Have you ever been in a vehicle accident or experienced any trauma to your jaw?YesNoNot Sure

Have you ever had any extractions? YesNoNot Sure

If Yes, did you experience prolonged bleeding afterwards? (If checked, please put date)

Have you ever had any of the following dental treatments? (Check and Date)

Are you being followed-up by a dental specialist?

Do you have any problems with your jaw joint (pain, sounds, limited opening, locking, popping)? YesNoNot Sure

Is there anything about the appearance of your teeth you would like to change?

Please list anything not mentioned above regarding your past dental history

Undersign:

CANCELLATION POLICY

Smiles Dentistry is dedicated to providing the highest quality dental care for our patients in a timely and efficient manner. In an effort to maintain that efficiency, we attempt to contact every patient at least 2 -3 days prior to their appointment as a courtesy reminder. However, it is the responsibility of the patient to keep their scheduled appointment. In the event you need to make any changes to your scheduled appointment, please let us know 48 hours in advance. Patients that do not call us at least 48 hours prior to their appointment may be subject to a missed appointment fee.

PATIENT CERTIFICATION AND APPROVAL

I the undersigned, certify that all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information.

PATIENT (GUARDIAN) CONSENT (FOR MINORS)

I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated, and I will assume responsibility for fees associated with these procedures.