New Patient Form 0% Complete1 of 7 To become a new patient of Premier Dental of St George, fill out the information below: Patient Information First Name Last Name Middle Initial Gender * Male Female Family Status * Married Single Child Other Date * Format: MM/DD/YYYY SSN * Birth Date * Format: MM/DD/YYYY Phone (Home) * Phone (Work) Best time to call Email Address * Mailing Address * Mailing Address Mailing Address Mailing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Reason for this visit Date of Last Dental Visit * Format: MM/DD/YYYY Have you ever had any of the following? Please check all that apply Checkboxes AIDS Allergies (Enter Details Below) Anemia Arthritis Artificial Valves/Joints Asthma Blood Disease/Transfusion Cancer/Chemotherapy Diabetes Dizziness Epilepsy Excessive Bleeding Fainting/Epilepsy/Seizures Glaucoma Growths Hay Fever Head Injuries Autoimmune Disease Heart Attack/Disease Heart Murmur Hepatitis A or B High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Pregnancy (Enter Details Below) Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Osteoporosis Thyroid Disease Stroke Tuberculosis Tumors Ulcers Venereal Disease Codeine Allergy Penicillin Allergy Aspirin Allergy Erythromycin Allergy Tetracycline Allergy Dental Anesthetic Allergy Latex Allergy Sulfa Allergy Do You Use Tobacco ADD or ADHD Heart Surgery Sensitivity to Hot/Cold Previous Drug/Alcohol Abuse Sensitivity to Sweets Clicking of the Jaw Pain (Joint, Ear, Side of Face) Difficulty Chewing Difficulty Opening/Closing Have you had teeth removed? (Enter Details Below) Local Anesthetic Reactions Do you have fears of concern (Enter Details Below) Allergies * Pregnancy Due Date * Tooth/Teeth Removal Details (Operation date, reason, etc.) * Any fears or concerns * For Women Do you take Birth Control? Yes No Are You Nursing? Yes No Immunosuppressants or Osteoporosis Medication Yes No Have you ever had any complications following dental treatment? * Yes No If yes, please explain: * Have you been admitted to a hospital or needed emergency care during the past two years? * Yes No If yes, please explain: * Are you now under the care of a physician or have you had any serious medical conditions? * Yes No If yes, please explain: * Name of Physician: * Physician’s Phone Number: * Do you have any health problems that need further clarification? * Yes No If yes, please explain: * Are you taking any prescription/over the counter drugs? Do you snore or have sleep apnea? * Yes No If yes, please explain: * Agreement To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any changes in my health, I will inform the doctors at the next appointment without fail. Signature of patient, parent or guardian * Date * Format: MM/DD/YYYY If you are human, leave this field blank. Next Page
