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Welcome
Appointment
Reviews
New Patients
Services
Gallery
Contact Us
New Patient Form Online
New Patient Form
Please complete as much of this form as possible.
When finished click on the 'SUBMIT' button at the bottom.
Thank you.
SECTION 1: About You
Patient Name
*
First Name
Last Name
What you prefer to be called: (Optional)
Date of Birth: (Month/Day/Year)
*
Social Security Number: (XXX-XX-XXXX)
Social Security number is required if you do not have a dental insurance card, or you do not know your insurance ID#. For cash paying patients without insurance, your SS# is required.
Gender
*
Male
Female
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
We offer convenient automated 'appointment reminders'
Provide your Cell Phone, Home Phone and Email Address to receive convenient automated 'appointment reminder' communications. (YOU CAN OPT OUT ANYTIME)
Cell Phone
(###)
###
####
Home Phone
(###)
###
####
Work Phone: (Optional)
(###)
###
####
Email Address
If you are a new patient, how did you hear about us?
Name of Employer
*
Name of employer is required if you have Dental Insurance through them.
Occupation
*
Status
*
Minor
Single
Married
Divorced
Separated
Widowed
SECTION 2: Insurance Information
Complete this section if you have Dental Insurance coverage
Name of Dental Insurance Company
Insurance Company Address: (Optional)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insurance Company Phone#: (Optional)
(###)
###
####
Insurance Group Number
Subscriber ID Number
The subscriber's ID# is required so that we can gather your insurance benefit coverage. If you do not know or have the ID#, your Social Security number is required.
If you are insured under another person:
If you have dental insurance under another person, such as a spouse or parent, their personal information is needed.
Name of Insured
First Name
Last Name
Gender
Male
Female
Relationship to Insured person
Spouse
Parent
Other
Insured person's date of birth (Month/Day/Year)
Insured person's employer
Insured person's Subscriber ID number
The subscriber's ID# is required so that we can gather the insurance benefit coverage. If you do not know or have the ID# for the insured person your coverage is under, their Social Security number is required.
If you have Secondary Insurance
Please type the insured person's Name, Date of Birth, Employer, name of Insurance Company, Group#, Insured person's ID# (Or Social Security# if you do not know or have that ID#)
SECTION 3: Event of Emergency
Name of person we should contact
*
First Name
Last Name
Contact Person's Phone Number
(###)
###
####
Relationship
*
Spouse
Parent
Other
Who is your Medical doctor?
Medical Doctor's Phone Number
(###)
###
####
SECTION 4: Confidential Health History (Optional)
This section can be completed at the time of your visit.
1. Is your general health good?
Yes
No
2. Has there been a change in your health within the last year?
Yes
No
3. Have you gone to the hospital or emergency room or had serious illness in the last three years?
Yes
No
4. Have you had problems with prior dental treatment?
Yes
No
5. Are you in pain now?
Yes
No
If you answered YES to the above five questions, please explain:
Have you ever experienced any of the following?
Chest pain (agina)
Fainting spells
Fever
Night sweats
Persistent cough
Coughing up blood
Bleeding problems
Blood in urine
Blood in stools
Frequent urination
Difficulty urinating
Ringing in ears
Headaches
Dizziness
Blurred vision
Bruise easily
Frequent vomiting
Jaundice
Dry mouth
Excessive thirst
Difficulty swallowing
Swollen ankles
Shortness of breath
Sinus problem
Others (not listed):
Have you ever had or do you have any of the following?
Heart disease
Family history of heart disease
Heart attack
Artificial joint
Stomach problems or ulcers
Heart defects
Pacemaker
Heart murmurs
Rheumatic fever
Hardening of arteries
High blood pressure
Seizures
Cosmetic surgery
AIDS/HIV
Surgeries
Hospitalization
Diabetes
Chemotherapy
Radiation
Arthritis, rheumatism
Emphysema or other lung disease
Kidney of bladder disease
Stroke
Eating disorders
Psychiatric care
Osteoporosis
Thyroid disease
Asthma
Hepatitis
Herpes
Canker or cold sores
Anemia
Liver disease
Eye disease
Transplants
Tuberculosis
Others (not listed):
Are you allergic of have you had a reaction to any of the following?
Aspirin
Penicillin or other antibiotics
Nitrous oxide
Valium or sedatives
Latex
Local anesthetic
Codeine or other opioids
Food
Metal
Others (not listed):
Are you taking or have taken any of the following in the last three months?
Recreational drugs
Over-the-counter medicines
Weight loss medications
Antidepressants
Opiods
Tobacco in any form
Alcohol
Bisphosphonate (Fosamax)
Herbal supplements
Antibiotics
Supplements
Aspirin
Others (not listed):
Woman Only
Pregnant
Nursing
Taking birth control pills
Section 5: All Patient Questions
This section can be completed at the time of your visit.
Do you have or have you had any other diseases or medical problems NOT listed on this form?
Yes
No
Have you had ever been pre-medicated for dental treatment?
Yes
No
Have you tested positive to Covid19?
Yes
No
Are you experiencing any ongoing or lasting symptoms or effects as a result?
Yes
No
Are you currently under the care of a physician or taking any medications for any of the conditions listed above?
Yes
No
Are there any issues of conditions your would like to discuss with the dentist in private?
Yes
No
CLICK ON 'SUBMIT' BUTTON TO SEND FORM
Dr. Truong will evaluate your information and we will keep a copy in your patient records - thank you!
POLICY INFORMATION
*
PENDING TREATMENT: Pending treatment listed on statement is an estimate to help plan expenses. Insurance covered amount may be different. Patient is responsible for all charges. ORDER OF TREATMENT: Treatment order may differ at time of visit. If additional treatment is needed patient will be informed. CO-PAY POLICY: It is our policy to collect co-pay at the time of service including any first visits for Crowns, Bridges & Dentures treatments. MISSED APPOINTMENT POLICY: A $75 charge per hour of the scheduled appointment will occur when patient is a "no-show" or did not provide 24-hours notice of cancellation or rescheduling.
CLICK BOX: I understand and agree to the missed appointment policy
We will contact you soon - Thank you!
