Patient
Forms

Fill out our new patient form

New Patient Form

Save some time on your first visit with us by filling out our new patient form ahead of time. You can either fill out the form and submit it here, or click the button below to download and print a paper version.

Download & Print Form

"*" indicates required fields

Step 1 of 2

50%

Date*

MM slash DD slash YYYY

Patient Information

Name*

First Middle Initial Last

Prefix

Dr.

Mr.

Mrs.

Miss

Birth Date*

MM slash DD slash YYYY

Age*

Marital Status

Single

Married

Widowed

Divorced

Separated

Social Security #

Home Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone #*

Work Phone #

Cell Phone #

Employer

Employer's Address

How long there?

Title

Where and best times to reach you:*

Who may we thank for referring you?

Previous/Present Dentist:

Date of Last Visit:

Person to notify in case of emergency:

Spouse Information

Name

First Last

Birth Date

MM slash DD slash YYYY

Social Security #

Employer

Work Phone #

Cell Phone #

Person responsible for account:

Relationship to patient:

Billing address:

Insurance Coverage

Primary Dental Insurance

Company Name

Primary Dental Insurance Address

Street Address Address Line 2 City State ZIP Code

Primary Dental Insurance Phone #

Primary Dental Insurance Group Policy #

Primary Dental Insurance Insured's Name

Relationship to Patient

Insured's Birthdate

Insured's SS #

Insured's Employer

Secondary Dental Insurance

Company Name

Secondary Dental Insurance Address

Street Address Address Line 2 City State ZIP Code

Secondary Dental Insurance Phone #

Secondary Dental Insurance Group Policy #

Secondary Dental Insurance Insured's Name

Relationship to Patient

Insured's Birthdate

Insured's SS #

Insured's Employer

Other Payment

I recognize that I am ultimately responsible for all fees related to my treatment. For that portion not covered by insurance, I will pay by:*

Cash or Check

Bank or Credit Card

Consent

Consent*

I consent

All professional services rendered are charged to the patient. Insurance claims are filed as a courtesy to our patients. However, the patient is responsible for all fees, regardless of insurance coverage. We request payment for services when rendered unless other arrangements have been made in advance with our accounts manager.

INSURANCE AUTHORIZATION AND ASSIGNMENT: I hereby authorize Dr. Dunavin to furnish information to my insurance carrier(s) concerning my dental treatment and I hereby assign to the dentist(s) all payment for services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance.

Signature*

Health Information

Do you have a personal physician?*

Yes

Physician's Name

Physician's Phone #

Date of last visit:

Your current health is:*

Good

Fair

Poor

Are you under the care of a physician?

Yes

Please explain:

Are you taking any prescriptions/over-the-counter drugs?*

Yes

Please list each one:

Why have you come to the dentist today?*

Are you currently in pain?*

Yes

Have you ever had a serious/difficult problem associated with any previous dental work?*

Yes

Specify:

Do you now or have you ever experienced pain/discomfort in your jaw joint?*

Yes

Your current dental health is:*

Good

Fair

Poor

Do you like your smile?*

Yes

Do your gums bleed?*

Yes

How many times/week do you brush?*

How many times/week do you floss?*

Type of bristles:*

Hard

Medium

Soft

Have you ever had any of the following diseases or medical problems?

Mitral Valve Prolapse?*

Yes

Artificial Bones/Joints?*

Yes

Artificial Heart Valves?*

Yes

Heart Murmur?*

Yes

Congenital Heart Defects?*

Yes

Rheumatic Fever?*

Yes

Heart Surgery/Pacemaker?*

Yes

Blood Transfusion?*

Yes

Hepatitis?*

Yes

HIV/AIDS?*

Yes

Drug/Alcohol Abuse?*

Yes

Shingles?*

Yes

Cancer/Chemotherapy?*

Yes

Sinus Problems?*

Yes

Difficulty Breathing?*

Yes

Anemia/Radiation Treatment?*

Yes

Psychiatric Problems?*

Yes

Epilepsy/Seizures?*

Yes

Kidney Problems?*

Yes

Diabetes?*

Yes

High/Low Blood Pressure?*

Yes

Fever Blisters?*

Yes

Severe/Frequent Headaches?*

Yes

Ulcers/Colitis?*

Yes

Emphysema/Glaucoma?*

Yes

Venereal Disease?*

Yes

Abnormal Bleeding?*

Yes

Hemophilia?*

Yes

Heart Attack/Stroke?*

Yes

Asthma/Arthritis?*

Yes

Hospitalized for any reason?*

Yes

Explain:

Please specify any serious medical conditions you have ever had:

Are you allergic to any of the following:

Penicillin?*

Yes

Tetracyclines?*

Yes

Aspirin?*

Yes

Latex?*

Yes

Erythromycin?*

Yes

Dental Anesthetics?*

Yes

Codeine?*

Yes

Sulfa?*

Yes

Please specify any other drugs you have reacted to in the past:

Does dental treatment make you nervous?*

Slightly

Moderately

Extremely

For Women

Are you taking birth control pills?

Yes

Are you pregnant?

Yes

Are you nursing?

Yes

Signature*

I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services with my informed consent that I may need during diagnosis and treatment.

Name

This field is for validation purposes and should be left unchanged.

Ready to love your smile?

Call us today!

Patient Forms

Fill out our new patient form

New Patient Form

Patient Information

Spouse Information

Insurance Coverage

Primary Dental Insurance

Secondary Dental Insurance

Other Payment

Consent

Health Information

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following:

For Women

Patient
Forms