New Patient Information

We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need help, please ask! We will be happy to help!

1Patient Information > 2Insurance Information > 3Confidential Health History > 4Privacy Practices and Office Policies
About You
Whom may we thank for referring you? *
Name Name * First Last
I prefer to be called I prefer to be called First Last
Sex

Sex Male Female
Check Appropriate Box

Check Appropriate Box Minor Single Married Divorced Widow Separated
Date of Birth Date of Birth * / MM / DD YYYY
Age
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Primary Phone Primary Phone * - ### - ### ####
Primary Phone Type *
Secondary Phone Secondary Phone - ### - ### ####
Secondary Phone Type
Additional Phone Additional Phone - ### - ### ####
Additional Phone Type
Email Address *
Employer
How Long There?
Occupation
Employer's Address Employer's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Person Responsible For Account
Same As Above? *

Same As Above? Yes No
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relation
Billing Address Billing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Employer
How Long There?
Occupation
Spouse Information
Same as above?

Same as above? Yes No
Do you have dental insurance? *

Do you have dental insurance? Yes No

New Patient Information

New Patient Information

About You

Person Responsible For Account

Spouse Information