New Patient Registration

Dental Insurance Information

Medical History

Do you have any current health problems?
Are you under a physician's care now?
Are you currently taking any medications?
Do you pre-medicate before dental visits?
Do you smoke or use any form of tobacco?
Are you pregnant?
Have you ever had, or do you have, any of the following conditions?
Are you allergic to any medications?

Dental History

Did you have x-rays taken at that visit?
How would you rate your dental health?
Do you trap food anywhere?
Do your gums bleed or feel irritated/swollen?
Have you had any periodontal/gum treatments?
Are your teeth sensitive to cold, sweets or biting?
Do you get cavities or break teeth often?
Have you had braces/orthodontics?
Do you grind or clench your teeth?
Do you get headaches, ear aches, or neck pain?
Would you like to change anything about your smile?
Are you apprehensive about dental treatment?
Financial Policy(Required)