New Patient Form

Patient Information

Dental Office:

Responsible Party Information


Parents/Guardians: Please note the following questions pertain to the patient being seen within our office(s). Please answer all questions for your child.
Are you under a physician's care?
Are you taking any medications or substances?
Are you taking a blood thinner?
Are you allergic to any medication or substances?
Do you have any problems with penicillin, antibiotics, local anesthetics (Novocaine) or other allergies?
Are you sensitive to any metals or latex?
Are you pregnant or suspect you are?
Do you take birth control medications?
Have you ever been treated for heart disease?
Do you have a pacemaker or an artificial heart valve implant?
Have you ever had rheumatic fever?
Are you aware of having a heart murmur?
Do you have high blood pressure?
Have you ever had a serious illness, major surgery, or cancer?
Have you ever had radiation treatment, chemotherapy, or any other?
Do you have any soreness, clicking, or popping in your jaw joint?
Do you have any blood disorders such as anemia, leukemia, hemophilia, etc?
Do you have any artificial joints / prosthesis?
Have you ever bled excessively after being cut or injured?
Have you ever received a blood transfusion?
Do you have any kidney or liver problems?
Do you have any stomach problems?
Do you have a history of seizures or epilepsy?
Are you a diabetic?
Do you have asthma?
Do you have any of the following: ADD, ADHD, or Autism Spectrum Disorder?
Are you HIV positive?
Do you have AIDS?
Have you had or do you test positive for hepatitis?
Do you or have you had tuberculosis?
Do you smoke, chew, use snuff or any other forms of tobacco?
Do you consume alcoholic beverages?
Do you habitually use controlled substances?

I understand that both the dentists and dental assistants may treat me or my child for the following dental procedures that may be necessary to provide dental treatment. I not only understand that I will be given explanation of performed treatments, but understand that the normal procedures for a first time patient may include a comprehensive or limited exam, dental cleaning, fluoride application, sealants and radiographs (x-rays) as necessary. However, this is subject to change depending on numerous factors including patient’s behavior, amount of future work needed and time.

In general terms the procedures you or your child may need include:



Decay exists between your child’s teeth and it is crucial to make sure they know how to floss and brush.


- OR -


Decay exists on the chewing surface due to inadequate brushing.

 SSC:So much tooth structure has to be removed due to decay that the tooth needs to be strengthened with a stainless steel crown so the patient can continue to chew with that tooth
 Pulpotomy:The decay, which is caused by bacteria, has reached the living tissue inside your child's tooth. This infected tissue needs to be removed

 The tooth cannot be restored due to decay.


- OR -


The tooth will not fall out on its own because there is a tooth that has not been resorbed by the body.

 Space Maintainer:Maintains the space when a baby tooth is lost early and the adult tooth is not ready to come in yet. Without the space maintainer, the space may close due to the pressure from the adult first molar.
 Sealants:Sealants are plastic resin that flow into the grooves on the chewing surface of your molars.
 Prophy:Removes plaque and food from the teeth, as well as polishes the teeth.
 X-Rays:X-rays are taken to help diagnose what procedures need to be done to ensure the health of your teeth.


Both my child’s treatment and suggested alternative methods of treatment, as well as the advantages and disadvantages of each, will be fully explained to me. We will advise you that although the best results are expected, there is no way within reason, of anticipating complications. Therefore, it is not possible to guarantee the results of the treatment. I recognize that some risks are associated with dental procedures: however, I also understand that the occurrence of such risks is remote.

I understand and accept that certain complications may be fatal or require medical intervention.