New Adult Patient Form

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New Adult Patient Form

How did you hear about us?

This information greatly helps us.

Financing Options

Are you interested in Dental Financing or Payment Plan?

Preference

Person Responsible for Payment
Info of person responsible for payment of account (if different from above)
Medical History

General *

Reactions *

Female Specific

Specific History
Do you, or have you had, any of the following: *
Dental History

Do you have any emotional concerns about your dentist visit?

Are your teeth sensitive to:

Do your gums bleed when:

Have you ever been sedated? If yes, select which types of sedation you've previously had.

Are you interested in, or have you thought about any of the following:

Medications

Name of medication:

Reason for medication:

Dosage

I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.

We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time. Please sign that you have read and understand our policy.

New Child Patient Form
Parent Information

How did you hear about us?

This information greatly helps us.

Financing Options

Are you interested in Dental Financing or Payment Plan?

Preference

Medical History

General *

Has your child experienced an unusual reaction to the following: *

Are your child's immunizations current?

Specific History
Has your child been treated for any of the following: *
Does your child have any of the following:
Dental History

Do you have any emotional concerns about your dentist visit?

Do you have concerns about any of the following:

Do your gums bleed when:

Medications

Name of medication:

Reason for medication:

Dosage

I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.

We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time. Please sign that you have read and understand our policy.

New Teen Patient Form
Parent Information

How did you hear about us?

This information greatly helps us.

Financing Options

Are you interested in Dental Financing or Payment Plan?

Preference

Medical History

General *

Has your Teen experienced an unusual reaction to the following: *

Are your Teen's immunizations current?

Specific History
Has your Teen been treated for any of the following:
Does your Teen have any of the following:
Dental History

Do you have any emotional concerns about your dentist visit?

Do you have concerns about any of the following:

Do your gums bleed when:

Name of medication:

Reason for medication:

Dosage

I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.

We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time. Please sign that you have read and understand our policy.

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