Click on Calendar, type the year 'YYYY' and pick the month & date.
New Patient Registration and Dental History

Please do not print the forms. Submit the forms online only.

Mr. Mrs. Ms. Dr.

  Last name

  MidI

  First name
    
    

Single Married Divorced Widowed
City
State
Zip
APT#
()- -
Work phone #:
()- - -
()- -


The Patient. The person responsible for payment.
City
State
Zip
APT#
()- - -
    



In an emergency who should be notified?
()- -


Dental History

How would you rate the condition of your mouth?
Excellent Good Fair Poor
I routinely see my dentist every :
3 Months 4 Months 6 Months 12 Months Not routinely

Had an unfavorable dental experience
Had trouble getting numb
Had any reactions to local anesthetic
Had/Have braces, orthodontic treatment
Had your bite adjusted
Had any teeth removed
Had complications from past dental treatment

*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)