NEW PATIENT Form

To help make your first visit as smooth and efficient as possible, we ask that all new patients complete the form below prior to their appointment. This allows our team to better prepare for your care and ensures a seamless experience from the moment you arrive. If you prefer, you may also download the form using the button provided and bring a completed copy with you to your visit.

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1000+ Clients
"Simply put, this is the best place in town for dentistry services."
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Associations and Memberships

Health History Form

Name
Address
Sex

Health Questions

If you answer yes to any of the 4 questions below, please stop and return this form to the receptionist.
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis

Dental Information

Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets, or pressure?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water? If so, how often?
Are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping, or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?

Dental Records

Testimonials

Patient Experience that speak for themselves

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