Please fill out the form below or download and print the form before your appointment. Download Patient Information Name* First Last Gender*MaleFemaleBirth Date* Date Format: MM slash DD slash YYYY Home PhoneCell Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Select one:*MinorSingleMarriedDivorcedWidowedSeparatedPatient's or Parent's employer*Work Phone*Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Spouse or Parent's Name First Last Employer*Work Phone Primary Care Physician*Phone NumberOther Physician(s)Phone NumberEmergency Contact*Phone Number*Email* Patient Medical HistoryPlease select if you're allergic to or if you have ever had any reaction to the following: Local anesthetics (e.g. Lidocaine) Penicillin Sulfa Drugs Codeine Aspirin Other List:*Have you ever been hospitalized for any surgical operation or serious illness?*YesNoIf yes, please explain reason:Are you taking any medication(s) including non-prescription medicine?*YesNoIf yes, please list:Are you under medical treatment now?*YesNoIf yes, please explain: Please select the following if you have or have had any of the following: High Blood Pressure Heart Attack Rheumatic Fever Swollen Ankles Fainting/Seizures Asthma Low Blood Pressure Epilepsy/Convulsions Leukemia Diabetes Kidney Disease Jaundice AIDS or HIV Infection Thyroid Problem Heart Disease Cardiac Pacemaker Heart Murmur Angina Frequently Tired Emphysema Cancer Arthritis Joint Replacement/Implant Hepatitis A Hepatitis B Hepatitis C Hepatitis D Sexually Transmitted Disease Stomach Troubles/Ulcers Chest Pains Easily Winded Stroke Hay Fever/ Allergies Tuberculosis Radiation Therapy Glaucoma Recent Weight Loss Liver Disease Osteoporosis Anemia Respiratory Problems Other WOMEN ONLY Are you pregnant or think you may be pregnant?YesNoAre you nursing?YesNoAre you taking birth control pills?YesNoPatient Dental HistoryPlease select the following if you have ever experienced any of the following problems in your jaw: Clicking Pain (joint, ear, side of face) Difficulty in opening or closing Difficulty in chewing Do you have frequent headaches?*YesNoDo you clench or grind your teeth?*YesNoHave you ever had any head, neck, or jaw injuries?*YesNoDo you have any sores or lumps in or near your mouth?*YesNoDo your gums bleed while brushing or flossing?*YesNoDo you sleep well?*YesNoHave you been diagnosed with sleep apnea?*YesNoHave you had a sleep study?*YesNoDo you snore or have been told you snore?*YesNoDo you have trouble breathing through your nose?*YesNoHave you ever had a negative experience in a dental office?*YesNoPlease describe:*CommentsThis field is for validation purposes and should be left unchanged.