New Patient Form Today's Date: _________________________

Please take a moment to enter your information to help us ensure the quality of your care is excellent.
PATIENT INFORMATION
Patient Name:
Last First MI Preferred Name
Title: Gender:  Male  Female Family Status:  Married  Single  Child  Other
Birth Date: / / / (dd/mm/yyyy) Email Address: ___________________________________________
Phone: ___________________ ____________________ _________________ _____
Mobile/Cell Home Work Ext
Address: ______________________________________ __________________ _____ ________________
Street City PV Postal Code

Driver's License #: _______________________________

Who may we thank for referring you to our office? ____________________________________________________

PERSON RESPONSIBLE FOR THE ACCOUNT (if different from above)

Name:
Last First MI Preferred Name
Birth Date: / / / (dd/mm/yyyy) Email Address: __________________________________________
Phone: ___________________ ____________________ _________________ _____
Mobile/Cell Home Work Ext

Address: ______________________________________ __________________ _____ ________________

Street City PV Postal Code
Driver's License # :_______________________________ Relationship to Patient: __________________________

INSURANCE INFORMATION
Name of Insured:
Last First MI Preferred Name

Insurance Co: _____________________________ Group No: _____________ Cert.I.D. #: ___________________

Insured's Employer: __________________________________

EMERGENCY INFORMATION
Relative/Spouse or local friend:_________________________________________________________________________
Complete Address: ______________________________________ __________________ _____ _________
Street City PV Postal Code
Phone: ___________________ ____________________ _________________ _____
Mobile/Cell Home Work Ext
Patient’s Name: _________________________________________ Today’s Date: _______________________________

Medical & Dental History

Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in
a way that watches out for your overall health and well-being.

Are you experiencing pain or discomfort? ...................................................................................................................  Yes  No

Has there been a change in your general health within the past year?........................................................................  Yes  No
Are you under the care of a physician?.........................................................................................................................  Yes  No
If so, what condition is being treated? ______________________________________________________________
Have you been hospitalized or had a serious operation or illness within the last 5 yrs?..............................................  Yes  No

Do you have or have you had any of the following diseases or problems? Please check all that apply:

 Heart Failure  Emphysema  Diabetes Type I /Type II

 Heart Disease or Attack  Cough  Thyroid Disease
 Angina Pectoris  Tuberculosis (TB)  X-ray or Cobalt Treatment
 High Blood Pressure  Asthma  Chemotherapy (Cancer, Leukemia)
 Heart Murmur  Hay Fever  Arthritis
 Rheumatic Fever  Sinus Trouble  Rheumatism
 Congenital Heart Lesions  Allergies or Hives  Cortisone Medicine
 Scarlet Fever  Artificial Joint  Glaucoma
 Artificial Heart Valve  Anemia  Pain in Jaw Joints
 Heart Pacemaker  Stroke  Fainting or Dizzy Spells
 Heart Surgery  Kidney Trouble  Epilepsy or Seizures
 AIDS  Ulcers  Cold Sores
 Hepatitis A  Bruise easily  STD or VD (Syphilis, Gonorrhea)
 Hepatitis B  Sickle Cell Disease  Blood Transfusion
 Hepatitis C  Psychiatric Treatment  Yellow Jaundice
 Liver Disease  Respiratory Problems  Nervousness

Are you taking any drugs or medication?......................................................................................................................  Yes  No

If so, What __________________________________________________________________________________
Are you allergic or have you reacted adversely to any drugs or medication?..............................................................  Yes  No
If so, which drugs _____________________________________________________________________________
When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest?............................  Yes  No
Do you ankles swell during the day?.............................................................................................................................  Yes  No
have you had any serious trouble associated with any previous dental treatment?...................................................  Yes  No
If so, please explain____________________________________________________________________________
Have you had abnormal bleeding associated with previous extractions, surgery or trauma?.....................................  Yes  No
Do you have a disease, condition, or problem not listed above that you think I should know?...................................  Yes  No
If yes, please explain ___________________________________________________________________________
Are you a smoker? If yes, how many per day?_______________................................................................................  Yes  No
FOR WOMEN ONLY: Are your pregnant? If Yes, When is the due date? _____________________  Yes  No
FOR WOMEN ONLY: Are you taking birth control pills?................................................................................................  Yes  No
If yes, name of contraceptive____________________________________________________________________

_______________________________________________ _______________________________________________
PATIENT or GUARDIAN (signature) GUARDIAN (print name of guardian)
 Dental History
How frequently do you brush your teeth?  3 (+) a day  Twice a day  Once a day  Weekly  Seldom
How frequently do you floss your teeth?  1 (+) a day  2-6 weekly  1-6 monthly  Seldom  Never
How frequently do you see your dentist?  6 Months  Yearly  Other____________________________
Last dental visit _____________ Last cleaning ________________ Last full mouth series of x-rays _________________________
Have you had sensitivity to:  Cold  Sweets  Heat  Other_____________
Do your gums bleed when:  Brushing  Flossing  spontaneously
Have you ever had any of the following: (Please check all that apply)
 Oral surgery  Periodontal treatment  Orthodontic treatment

 Bite adjustment  Bite plate  Other appliance. Specify_________

Do you have any dental implants?................................................................................................................................  Yes  No

Do you suffer from pain and/or swelling of your gums?..............................................................................................  Yes  No
Are you aware of any loose teeth? If so, where?..........................................................................................................  Yes  No
Do you chew on only one side of your mouth? If so, why?..........................................................................................  Yes  No
Habits, do you - grind or clench your teeth during the day or night?.........................................................................  Yes  No
- mouth breathe while awake or asleep?............................................................................................  Yes  No
- bite your lips or cheeks regularly?....................................................................................................  Yes  No
- hold any foreign objects with your teeth?........................................................................................  Yes  No
Does any part of your mouth hurt when clenched?......................................................................................................  Yes  No
Does your jaw crack or pop when opened widely?.......................................................................................................  Yes  No
Do you have any difficulty in opening or closing your jaw?..........................................................................................  Yes  No
Do you have any pain in your ears?..............................................................................................................................  Yes  No
Do you gag easily?.........................................................................................................................................................  Yes  No
Have you experienced any growth or sore spots in your mouth? If so, where?...........................................................  Yes  No
Are you concerned about the appearance of your teeth, and if so what would you like to see changed?..................  Yes  No
Specify:__________________________________________________________________________  Yes  No

Would you rate your current dental health as:  Excellent  Good  Fair  Poor
Is your sugar intake  High  Medium  Low
What is your brushing habits  Vigorous  Light
Do you have any emotional concerns regarding your dental visit?
 Fear  Pain Time  Money  Embarrassment  Other concerns __________

GENERAL RELEASE
I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not
knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my
medical-dental history. I authorize the dentist to perform previously discussed diagnostic procedures and treatment as may be
necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my
physician being contacted if necessary. I acknowledge that it is my responsibility to provide payment for dental services provided for
myself or my dependents; I will assume responsibility for fees associated with these services.

_______________________________________________ _______________________________________________
PATIENT or GUARDIAN (signature) GUARDIAN (print name of guardian)

Date: _____________________________________
For all patients with coverage through an insurance company

Electronic Dental Submissions (EDI) Acknowledgement Form

I _______________________________ (print your name), authorize release; to my dental benefits plan administrator
and the CDA, information contained in claims submitted electronically. I also authorize the communication of
information related to the coverage of services described to the named dentist. This authorization shall continue in
effect until the undersigned revokes the same.

__________________________________________ Date: ________________________

Signature of patient, parent or guardian

Appointment Cancellation –Rescheduling Policy

To all of our valued patients,

We understand that unplanned issues may come up and you may need to
reschedule your appointment. Should this happen, we respectfully ask for 48 hours
notice to change your scheduled appointment(s).

Our doctors & hygienists want to be available for your needs and the needs of all
our patients. When a patient does not show up for a scheduled appointment,
another patient loses an opportunity to be seen.

For those appointments cancelled or rescheduled without 48 hours notice there is a

fee of $80.00.

Thank you for being a valued patient and for your understanding and cooperation
with this policy.

This policy will enable us to open otherwise unused appointments to better serve
the needs of all patients.

The Staff of MY Prosthodontic Dental Clinic

New Patient Signature:___________________