Welcome to our office! To assist us in serving you, please complete the following confidential form.

Birth date :



Date of last dental visit :
Date of last cleaning :
Date of last dental x-ray :

Do you have or have you had any of the following? (Please check any that apply)

Issue with previous treatmentsBad breathBleeding gumsBlisters on lips or mouthChew on one side of mouth
SmokingClicking or popping jawDentureFood collection b/t teethGrinding teeth
Gums swollen or tenderJaw pain or tirednessLoose teeth or broken fillingsMouth breathing
Orthodontic treatmentPain around earPeriodontal treatmentSensitivity to cold / heat / sweets


Do you have or have you had any of the following? (Please check any that apply)

Cancer or tumorHeart diseaseArtificial joint or valveHigh or low blood pressurePacemakerTuberculosis or other lung problemsKidney diseaseHepatitis or other liver diseaseAlcoholismBlood transfusionDiabetesNeurologic conditionEpilepsy, seizures, or fainting spellsEmotional conditionArthritisHerpes or cold soresAIDS or HIV positiveMigraine headaches or frequent headachesAnemia or blood disordersAbnormal bleeding after extractions, surgery, or traumaHayfever or sinus troubleAllergies or hivesAsthma

Are you allergic to, or have you reacted adversely to:

Latex materialsPenicillin or other antibioticsLocal anesthetics ("Novocain")Codeine or other narcoticsBarbiturates, sedatives, or sleeping pillsAspirin

Are you taking any of the following?

AspirinAnticoagulants (blood thinners)Antibiotics or sulfa drugsHigh blood pressure medicineAntidepressants or tranquilizersInsulin, Orinase, or other diabetes drugNitroglycerinCortisone or other steroidsOsteoporosis (bone density) medicine


May be pregnant, expected due date Taking hormones or contraceptives

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the dentist.
I understand that I am financially responsible for any balance.

Date :