New Patient Form

Are you currently our patient?

Patient Information

Title

First Name

Last Name

Date of Birth

Sex

Female Male Other

Address

State

Postal / Zip Code

Country

Mobile

Home Phone

Email

Care Card Number

Please select which method you prefer as your primary form of communication with our clinic:

Home Phone Mobile Email Any

Do you have someone that is assigned to make your decisions?

Yes No

If You Are Selecting Yes (Optional)

(Optional)

1

Patient Information

2

Emergency/Physician Information

3

Medical & Dental History

4

Dental Insurance

5

Office Policies/Submission

Emergency Contacts

Name

Relationship

Phone

Family Doctor Information

Physician's Name

Phone

Do you have dental Insurance *

Yes No

APPOINTMENTS:

Appointment times are reserved especially for you. If you are unable to keep an appointment, please allow two business days notice to avoid a late cancellation or missed appointment fee of $100.

PERMISSION TO TREAT:

This is to certify that I, the undersigned, consent to dental and oral surgery procedures as determined necessary or advisable, including the use of local anesthesia.

NOTE: IT IS IMPORTANT THAT ANY CHANGES TO YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE

APPOINTMENT CHANGES / CANCELLATIONS:

If you need to make changes to the appointment date/time, please call our office directly. There will be a $100 fee for any no show or last minute cancellations.

Please give our office at least 3 business days notice.