Welcome We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to work with you in maintaining your dental health. Click on the below button to download and fill it offline. Download Form Patient InformationName* First name Last name Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Soc. Sec. #*Home PhoneCell PhoneEmail* Sex*MFAgeBirthdate Marital StatusSingleMarriedWidowedSeparatedDivorcedPatient Employed byOccupationBusiness PhoneBusiness AddressBusiness Email Whom may we thank for refering you?Notify incase of emergencyEmail Home PhoneCell PhoneMobile Phone Primary InsurancePerson responsible for account First Last Relation to PatientBirthdate Soc. Sec. #Address (if different from Patient) Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail Person Responsible employed byOccupationBusiness AddressBusiness PhoneBusiness Email Insurance CompanyPhoneEmail Contract #Insurance ID #Subscriber #Number of dependants under this plan Additional InsuranceIs Patient covered by additional InsuranceYesNoSubscriber nameRelation to PatientBirthdate Address (if different from Patient) Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail Soc. Sec. #Subscriber Employed byBusiness PhoneBusiness Email Insurance CompanyBusiness PhoneBusiness Email Contract #Group #Subscriber #Number of other dependents under this plan Dental HistoryWhat would you like us to do today?Are you in dental discomfort today?Former DentistDentist AddressDentist Email Dentist PhoneDate of last dental careDate of last X-raysCheck Yes or No if you have had problems with any of the following:Bad breath Yes No Food Collection between Teeth Yes No Periodontal Treatment Yes No Sensitivity to Sweets Yes No Bleeding Gums Yes No Grinding or Clenching Teeth Yes No Sensitivity to Cold Yes No Sensitivity When Biting Yes No Clicking or Popping Jaw Yes No Loose teeth or broken fillings Yes No Sensitivity to Hot Yes No Sores or growths in mouth Yes No How often do you brush?Floss?How do you feel about the appearance of your teeth?Have you ever experienced an adverse reaction during or in conjuction with a medical or dental procedure? Yes No Other Information about your dental health or previous treatment Medical HistoryPhysician NamePhoneDate of last visit Have you ever had any serious illness or operations?YesNodescribe*Are you currently under Physician care?YesNodescribeHave you ever had blood transfusionsYesNoGive approximate datesHave you ever taken Fen_phen/Redux?YesNoWomen: Are you pregnant?YesNoNursing?YesNoTaking birth control pillsYesNoCheck Yes or No if you have had problems with any of the following:AIDS/HIV PositiveYesNoCough, persistentYesNoJaw painYesNoShinglesYesNoAnaphylaxisYesNoCough up bloodYesNoKidney disease/malfunctionYesNoShortness of breathYesNoAnemiaYesNoDiabetesYesNoSkin rashYesNoAnthritis, RheumatismYesNoEpilepsyYesNoLiver diseaseYesNoSpina bifidaYesNoArtificial heart valvesYesNoFaintingYesNoMaterial allergies (latex, wool, metal, chemicals)YesNoStrokeYesNoArtificial JointsYesNoFood allergiesYesNoSurgical implantYesNoAsthmaYesNoGlaucomaYesNoMitral valve prolapseYesNoSwelling of feet/anklesYesNoAtopic (allergy prone)YesNoHeadachesYesNoNervous problemsYesNoBack problemsYesNoHeart murmurYesNoPace maker / heart surgeryYesNoThyroid disease/malfunctionYesNoBlood diseaseYesNoHeart problemsYesNoCancerYesNoPsychiatric careYesNoTobacco habitYesNoChemical dependencyYesNoHemophillia / abnormal bleedingYesNoRapid weight gain/lossYesNoTonsillitisYesNoChemotheraphyYesNoHerpesYesNoRadiation treatmentYesNoTuberculosisYesNoCirculatory problemsYesNoHepatitisYesNoRespiratory diseaseYesNoUlcer / ColitisYesNoCortisone treatmentsYesNoHigh blood pressureYesNoRheumatic / Scarlet feverYesNoVenereal diseaseYesNoIs patient currently taking any medication? if yes list allDoes patient have drug allergies? if yes list all This iframe contains the logic required to handle AJAX powered Gravity Forms.