New Patient Exam

Today's Date:   Name:

Name Pronunciation:Adult  Child

Responsible Party if different from Above:

Address:

Home Phone: Office or Work Phone:

Referral Source:

Other Family members who are patients?

Reason for call?  Exam  Emergency  Other

Emergency Questions:

Toothache  Lost filling or crown   Broken Tooth

Hurting On/Off     Hurting Constant    Sensitive to Hot/Cold 

Sensitive to Pressure   Swelling    Mobility    Temperature

Are you taking any medications? Yes  No 

If yes, what medication? 

Other:  Other: Please Explain...

 Where?

Exam Questions:

Last Dental Exam/Cleaning: 

Last X-Rays taken:   

Previous Dentist:   

Previous Dentist's Location? Phone:

May we have permission to contact your previous Dentist?  Yes  No

Financial Arrangements

Dental Insurance   Company Name:

Cash   Visa   Mastercard   ATM