New Patient Form

 
Section #1 PATIENT QUESTIONNAIRE
Name *
Name
Date of Birth *
Date of Birth
Phone Number *
Phone Number
Address *
Address
The reason for your appointment *
Business Address
Business Address
Name of Spouse
Name of Spouse
Phone Number
Phone Number
Optional
Terms & Condition *
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental service performed without prior financial arrangements, must be paid for in cash at the time services are performed. I understand that the fee estimate listed for this dental case can only be extended for a period of six months from the date of the patient's examination. In consideration of the professional services rendered to me, or at my request, by the Doctor and/or his staff, I agree to pay, therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be billed unless objected to, by me, in writing, within the time for payment thereof. Additionally, I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you, or your assigns, to telephone me at my home or at my work to discuss matters related to this form.
Section #2 MEDICAL HISTORY
Physician Phone Number
Physician Phone Number
Date of your last medical examination
Date of your last medical examination
Have you ever been treated for any of the following? *
Please check all that apply
Are you allergic to any of the following?
Section #3 FOR WOMEN ONLY
Are you pregnant? *
Due Date?
Due Date?
Are you Nursing?
Are you taking Oral Contraceptives?
Are you taking Hormone Supplements?
Section #4 DENTAL HISTORY
Former Dentist's phone number
Former Dentist's phone number
Are you currently experiencing any pain or discomfort?
Have you ever had an unfavorable dental experience?
Do your gums bleed when brushing your teeth?
Do you have an unpleasant odor or taste in your mouth?
Do you smoke?
Are you satisfied with the appearance of your teeth and smile?
Have you ever had Periodontal Surgery/Periodontal Root Planning?
Have you ever had Oral Surgery
Have you ever had Orthodontic Treatment?
Do you clench/grind your teeth?
Do you have chronic headaches, or neck and shoulder pains?Have you ever experienced your jaw locking/clicking?
Have you ever experienced your jaw locking/clicking?
Does food catch between your teeth?
Which side do you favor when chewing?
How often do you brush?
Section #5 NEW PATIENT QUESTIONNAIRE
Please help us help you by filling out the following information. It is our intention to make your dental experience with us a comfortable and productive one. Your complete and specific information is essential to our communication and achieving the optimal results that are possible.
Goals relating to your teeth and smile
Section #6 Aesthetic Profile
You're lips? Your face?
If so, which procedures?
If not, please explain.
Section #7 TEMPOROMANDIBULAR JOINT DYSFUNCTION QUESTIONNAIRE
Optional
Check any area where you have pain or soreness.
Section #8 CONSENT
QUESTIONAIRE COMPLETION *
CONSENT FOR TREATMENT *
Date *
Date
INSURANCE CONTRACT *


Office Hours

9am - 6pm Monday

9am - 6pm Tuesday

9am - 6pm Wednesday

9am - 6pm Thursday

9am - 1pm Friday

141 N Camden Dr, Suite 1280
Beverly Hills, CA, 90210