New Patients

New Patient Paperwork Download

-Or-

Complete the online form:

Patient Information

EMERGENCY INFORMATION

In case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address:

EMPLOYMENT INFORMATION

Insurance Information

Primary

Secondary Insurance (if applicable)

PREVIOUS DENTIST INFORMATION

DENTAL HISTORY

Are you currently having dental discomfort?

Any unhappy/unpleasant dental experiences?

Any injuries to mouth/teeth/head?

Any missing teeth other than wisdom teeth or orthodontic extractions?

Have missing teeth been replaced?

Orthodontic appliances now or in the past?

Gums bleed when brushing or flossing?

Concerned about gum disease? History of gum disease?

Any concerns about the appearance of your teeth?

Does it hurt to bite or chew?

Do you clench or grind your teeth? If so, do you wear a night guard or splint?

Do you want your mouth properly restored and pain free?

Does any type of dental treatment make you nervous? If yes, please explain below:

CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS:

Any mouth habits? (thumb sucking, nail biting, mouth breathing, nursing/bottle habits, pacifier, etc.)

Any unusual speech habits?

Any lost teeth?

Does the patient receive assistance with brushing and flossing?

PRIMARY PHYSICIAN INFORMATION

MEDICAL HISTORY

GENERAL HEALTH:

Under a physician’s care now?

Any hospitalization in the past 5 years?

Any serious illnesses/surgeries?

Use tobacco in any form?

Is pre-medication required before dental visits due to heart condition or artificial joint?

Taking any prescription or daily OTC medications/drugs? If yes, list details in the Medication Section.

FEMALE PATIENTS: Currently Nursing Currently Pregnant

Do you know of any reason why routine dental procedures might pose a risk to you, our staff, or other patients?

Is there anything important about your medical condition we have not asked?

Do you have any of the following? Please check any that apply to you.

ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):

MEDICATION INFORMATION

ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

Enter the drug name, dosage and reason prescribed for any medications that you are currently taking.

I have read and agree to the Hoffman Dental Guidelines.