1 form to complete.

New Patient Exam EForm

Patient Information

Personal Information

NEW PATIENT HEALTH HISTORY FORM

DENTAL INFORMATION

In the following sections, please select whichever applies. Your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during you initial visit you may be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

MEDICAL INFORMATION

Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking and your health History have a important relationship with your Dental Treatment. Please answer the following question.

Women Only

Health History

Please go over the following section and indicate which of the following you have or have had. If you need to add any further information, please ente

CHILDREN ONLY

Insurance Information

Primary Insurance
Secondary Insurance
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered.
I understand that providing incorrect information can be dangerous to my health.
I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors, and/or health practitioners..
I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. 
I understand that during the course of the procedure(s), unforeseen conditions may arise which necessitate procedures different from those contemplated. I, therefore, consent to the performance of additional procedure(s).
I understand that I am responsible for all fees regardless of insurance coverage.
I also understand that as treatment progresses the above fees may have to be adjusted, but that I will be informed of these adjustments and how they will affect my payment.
In the event that my payments are not received within 30 days of their due date, I agree to pay all costs of collections, including, but not limited to reasonable attorney's fees.