New Patient Form

Patient information

Let’s start with the basics.

Have you already made an appointment? Preferred office First name Last name Preferred name Date of birth Social Security number Sex Marital status

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Contact information

How can our team reach you?

Mailing address City State ZIP code Cell phone Home phone Work phone Email address Employer

Emergency contact

Emergency contact name Emergency contact phone

How did you hear about us?

Family / friend name Other referral details

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Responsible party & insurance

Tell us about the account and your insurance coverage.

Are you the guarantor of the account?

If someone else is responsible, add their information

Guarantor full name Relationship to patient Mailing address City State ZIP code Home phone Work phone Cell phone Date of birth Employer Social Security number

Preferred method of payment

Do you have dental insurance?

If you have insurance, add your coverage details

Insurance company Group number Member / ID number Insurance phone Insurance address Policyholder full name Policyholder date of birth Policyholder SSN Policyholder employer Policyholder work phone Relationship to patient

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Dental history

Tell us about your dental health and concerns.

Previous dentist Previous dental clinic How many times a day do you brush? How many times a week do you floss? How would you rate your smile? Do you require antibiotic premedication?

Do you have any of these concerns?

Red, swollen, or bleeding gums Tooth pain Sensitivity to hot, cold, or sweets Broken or chipped teeth or fillings Snoring Dental anxiety

Anything else you would like us to know?

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Consent & signature

You can return to any previous step to review your entries.

Please review the consent form, financial policy, privacy practices, notice of non-covered services, and social media consent before signing.

Read patient forms and policies →

I have reviewed the consent form, financial policy, privacy practices, and notice of non-covered services. I confirm that the information I have provided is accurate to the best of my knowledge. Full name / typed signature Relationship to patient

Review your information

Please check your answers using the steps above and complete the acknowledgments and signature fields.

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Your First Visit Starts Here

Patient information

Contact information

Emergency contact

Responsible party & insurance

Medical history

Sleeping and breathing

Additional health questions

Dental history

Consent & signature

Review your information