Initial Visit Form

Filling out this information and sending it to us will save you time at your first visit. Simply send us the form on this page and we’ll already have your information when you show up for your appointment:

Personal Information

Today's date:
First name:
Last name:
Date of birth:
Sex:
Email:
Street address:
City:
State:
Zip:
Home phone:
Cell phone:
Work phone:
Social Security #:

Work Information

Employer:
How long?
Work street address:
Work city:
Work state:
Work zip:

Family Information

Spouse first name:
Spouse last name:
Spouse date of birth:
Spouse social security #:
Spouse employer:
Spouse work street address:
Spouse work city:
Spouse work state:
Spouse work zip:
Work phone:
Relative not living with you:
Relationship:
Their address:
Their phone:

Dental Insurance Information

Primary insurance company:
Subscriber name:
Date of birth:
Social security #:
Plan ID#:
Secondary insurance company:
Subscriber name:
Date of birth:
Social security:
Plan ID#:

Dental History

When was your last dental visit?
When was your last dental cleaning?
What is the main purpose for your visit to our office today?
Do your gums bleed when you brush or floss?
Do you have any problems with bad breath?
Would you like to know if we notice any breath problems?
Do you have any teeth that are sensitive to cold/hot/sweets/chewing?
Would you like to keep your own teeth?
Do you like the way your smile looks?
Would you make any changes to your smile if you could?

Did someone refer you to our office?

Do you smoke?
If so, how often?
If so, for how long?

Do you chew tobacco?
If so, how often?
If so, how long?

Are you now under the care of a physician?
If so, what is the name of the physician?
For what conditions?

Have you ever been hospitalized for illness or surgery?
Were there any problems with this?

Have you had a general anesthetic in a hospital?
Were there any problems with this?

Has any family member had an adverse reaction to anesthesia?

Do you take any medication? (prescription or non-prescription)
Please list name and dosages…

Do you use any recreational drugs?
Please list names and how often used…

Do you have or have you ever had any of the following:
Allergy to any drug or medication?
If so, please list drug name and problem.
Allergic reaction to any latex products?
Have you ever taken the diet drug combination Fen-Phen?
Adverse reaction to any anesthetic or anesthesia?
Heart disease or cardiovascular disease?
Heart attack?
Angina?
High blood pressure?
Low blood pressure?
Rheumatic fever?
Congenital heart defects or problems?
History of heart disease in your family?
Artificial heart valves, artificial joints or other implants?
Diseases or surgery of eyes, ears, nose or throat?
Special problems of head, neck or jaws?
Do you wear contact lenses?
Do you have TMJ or jaw joint problems?
Breathing problems?
Lung or pulmonary disease?
Asthma?
Aspirin allergy?
Unusual bleeding problems?
Blood disorder?
Blood transfusion?
Immune system suppression or compromise?
Frequent infections?
Anemia?
Liver disease?
Hepatitis?
Jaundice or yellowing of the skin or eyes?
Diabetes?
Low blood sugar?
Ulcers?
Intestinal disease?
Kidney disease?
Thyroid disease?
Seizures or epilepsy?
Steroid or cortisone treatment?
Arthritis?
Cancer treatment?
Chemical dependency?
Psychiatric care?
Family history of inherited diseases?
Any disease, condition or problem not mentioned above that the doctor should know about?

Women Only

Date of last menstrual period?
Are you or may you be pregnant?
Are you breast feeding an infant?
Are you taking birth control pills?

The information that I have provided today is correct to the best of my knowledge. I understand that this information will be held in strict confidence and it is my responsibility to inform this office of any changes in my medical status. I am also aware that the doctor may take photographs for diagnosis or documentation and that I give permission for these photographs to be used for scientific and educational purposes.