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• WELCOME!
• The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health.
• Please fill out these forms completely. The better we communicate, the better we can care for you.

• TODAY'S DATE:

• NAME:

• last
• first
• middle
• Mr. Mrs. Ms. Dr.

• BIRTHDATE:
• AGE:
• SSN:

• HOME ADDRESS:

• city
• state
• zip

• Single

  Married

  Divorced

  Widowed

  Separated

• Home #:
• Cell #:

• Work #:
• Ext #:
• Email:

• Dental Insurance
• Medical Insurance

• Person financially responsible:

• IF DIFFERENT FROM PATIENT (relationship to patient)

• Where & when are best times to reach you?

• Who may we THANK for referring you?

• Previous Dentist:
• Last dental visit:

• Primary Care Physician
• Phone:

• Referring Physician
• Phone:

• Sleep Physician
• Phone:

• Other Physicians you are under the care of:

• DENTAL HISTORY / INFORMATION

• Why have you come to the dentist today?

• Do you have or have you experienced any of the following: (please check)

• 	Serious/difficult problem associated with any dental work
  	Pain or discomfort in your jaw joints (TMJ)
  	Face sore or feel tight in the morning
  	Jaw sometimes difficult to open or close, clicking or popping
  	Clenching or grinding your teeth
  	Teeth sensitive to cold, heat, pressure or sweets
  	Unpleasant taste in your mouth or persistent bad breath
  	Teeth loose or shifting
  	Bleeding gums

• How would you evaluate your dental health:

• Excellent

  Good

  Fair

  Poor

• Do you have any skin allergies? (This would include reactions to wearing jewelry)

• Yes

  No