We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we’ll be glad to help you. We look forward to working with you in maintaining your dental health.


    Soc Sec #

    City State Zip
    Home Phone Cell Phone
    Email* Sex MF Age DOB
    Employed by Occupation
    Business Address
    Business Phone Business Email
    May we call you at work? YN
    Notify in case of emergency
    Home Phone Cell Phone
    Business Phone Email

    Whom may we thank for referring you?


    Do you have any family members that come to Gentle Dental? If so, who?



    Person Responsible for Account

    Relation to Patient DOB Soc Sec #
    Address (if different from patient)
    City State Zip
    Home Phone Cell Phone
    Employed by Occupation
    Business Address
    Business Phone Email
    Insurance Company Phone
    Insurance Email Contract #
    Group # Subscriber ID


    Is patient covered by additional insurance? YN

    Subscriber Name
    Relation to Patient DOB Soc Sec #
    Address (if different from patient)
    City State Zip
    Home Phone Cell Phone
    Employed by Occupation
    Business Address
    Business Phone Email
    Insurance Company Phone
    Insurance Email Contract #
    Group # Subscriber ID



    Physician’s name Phone
    Date of last visit Have you had any serious illnesses or operations? YN
    If yes, please describe

    Are you in good health? YN
    Has there been any change in your general health in the past year? YN
    Are you currently under physician care? YN
    If yes, describe
    Have you ever had a blood transfusion? YN
    If yes, give approximate dates
    Have you ever taken Fen-Phen/Redux? YN
    Women: Are you pregnant? YN
    Nursing YN
    Taking Birth Control Pills? YN


    Are you using any of the following?

    Antibiotics? YN
    Anticoagulants (blood thinners)? YN
    Aspirin or drugs such as Motrin, Aleve, Ibuprofen? YN
    High Blood Pressure medications? YN
    Steroids (Cortisone, etc.)? YN
    Weight loss medications (Fen-Phen)? YN
    Tranquilizers and/or antidepressants? YN
    Insulin or Oral Anti-Diabetic drugs? YN
    Digitalis, Inderal, Nitroglycerin or other heart drug? YN
    Recreational Drugs? YN
    Are you taking or have you ever taken Bisphosphonates (such as Fosamax or Actonel for osteoporosis, or chemotherapy for multiple Myeloma, etc.)? YN


    Please list any and all medications taken, including prescription and over-the-counter medications, herbal or holistic remedies, vitamins or minerals:


    Indicate which of the following you have had or have at present:

    YN AIDS/HIV Positive
    YN Anaphylaxis
    YN Anemia
    YN Arthritis, Rheumatism
    YN Artificial heart valves
    YN Artificial joints
    YN Asthma
    YN Atopic (allergy prone)
    YN Back problems
    YN Blood disease
    YN Bruise easily
    YN Cancer
    YN Chemotherapy
    YN Chest Pain
    YN Circulatory problems
    YN Cold Sores/Fever Blisters
    YN Cortisone treatments
    YN Cough, persistent
    YN Cough up blood
    YN Diabetes

    YN Epilepsy or Seizure
    YN Fainting or Dizzy Spells
    YN Food Allergies
    YN Glaucoma
    YN Headaches
    YN Heart murmur
    YN Heart problems


    YN Hemophilia/Abnormal bleeding
    YN Herpes
    YN High blood pressure
    YN Jaw pain
    YN Kidney disease or malfunction
    YN Liver disease
    YN Material allergies

    (latex, wool, metal, chemicals)

    YN Mitral valve prolapse
    YN Nervousness/Anxiety
    YN Neurological Disorders

    YN Pacemaker/Heart surgery
    YN Psychiatric care
    YN Rapid weight gain or loss
    YN Radiation treatment
    YN Respiratory disease
    YN Rheumatic/Scarlet fever
    YN Shingles
    YN Shortness of breath
    YN Spina Bifida
    YN Stroke
    YN Surgical implant
    YN Swelling of feet or ankles
    YN Thyroid disease/malfunction
    YN Tobacco habit
    YN Tonsillitis
    YN Tuberculosis
    YN Ulcer/Colitis
    YN Venereal disease


    Are you allergic to or have you had an adverse reaction to:

    Local Anesthesia (Novocain, etc)? YN
    Penicillin or other antibiotics? YN
    Sedatives, Barbituates? YN
    Aspirin or Ibuprofen? YN
    Codeine or other pain killers? YN
    Latext or Rubber Products? YN
    Jewelry or Metals? YN

    Other allergies or reactions? Please list:


    Do you have a history of Alcohol or Chemical Dependency or Emotional Disorder? YN

    Do you have any other disease, condition or problem not listed above that you think the doctor should know about? YN



    What would you like us to do today?
    Are you in dental discomfort today? YN
    Former Dentist Address
    Dentist’s Email Phone
    Date of last dental care Date of last x-rays Date of last hygiene visit


    Have had problems with any of the following:

    YN Bad breath
    YN Bleeding gums
    YN Clicking or popping jaw
    YN Sensitivity to sweets

    YN Food collection between teeth
    YN Grinding or clenching teeth
    YN Loose teeth or broken fillings
    YN Sensitivity when biting

    YN Periodontal treatment
    YN Sensitivity to cold
    YN Sensitivity to hot
    YN Sores or growths in mouth


    How often do you brush?
    How do you feel about the appearance of your teeth?
    Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? YN
    Other information about your dental health or previous treatment


    Are you apprehensive about dental work? NoSlightModerateExtreme
    Are you interested in Sedation Dentistry? YN
    Are you interested in learning more about?
    InvisalignTeeth WhiteningImplantsCerec One Visit DentistryBotox and Juvederm


    Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
    With whom may we discuss your dental or financial situation? Please list name(s) and relationship.


    I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to
    inform this office of any changes in my medical status.
    I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I
    authorize the use of this signature on all insurance submissions.
    I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges
    whether or not paid by insurance.