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Streamline Your Dental Visits

We recommend completing your new patient forms before your visit. You can access the forms below.

Financial Agreement

Registration Form

Medical History Form

URL

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

Personal

Name

First Last

Birthdate

MM slash DD slash YYYY

SS#

Gender

Married

Work Phone

Wireless Phone

Wireless Carrier

Preferred Contact Method

HmPhone

WkPhone

WirelessPh

Preferred Contact Method for Confirmations

HmPhone

WkPhone

WirelessPh

Preferred Contact Method for Recall

HmPhone

WkPhone

WirelessPh

Student Status if Dependent Over 19 (for Ins)

Non Student

Full Time

Part Time

How did you hear about us?

(If someone referred you here, please write down their name so we can thank them.)

Address and Home Phone

Check box if same for entire family

Address

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

Phone

INSURANCE POLICY 1

Your Relationship to Subscriber

Self

Spouse

Child

Subscriber Name

Subscriber ID #

Insurance Company

Home Phone

Employer

Group Name

Group #

Please present insurance card to receptionist.

Insurance Policy 2

Your Relationship to Subscriber

Self

Spouse

Child

Subscriber Name

Subscriber ID #

Insurance Company

Home Phone

Employer

Group Name

Group #

Comments

"*" indicates required fields

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

Patient's Name:*

First Last

Birth Date:

MM slash DD slash YYYY

MEDICAL HISTORY QUESTIONNAIRE

Please answer all questions by checking a box under YES or NO. Your responses will be held strictly confidential and will only be used to help assess your medical condition. If you have any hesitations, please express your concern to a member of our office.

Do you have, or did you ever have, any of the following?

Cardioyascular:

High blood pressure

Yes

Heart disease from childhood

Yes

Heart murmur

Yes

Rheumatic fever

Yes

Use of Fen-Phen

Yes

Pacemaker

Yes

Vascular graft

Yes

Heart valve replacement

Yes

Heart attack

Yes

Heart surgery

Yes

Congestive heart failure

Yes

Angina (chest pain)

Yes

Irregular heart beat

Yes

Stroke

Yes

Increased cholesterol

Yes

Multiple Sclerosis

Yes

Cerebral palsy

Yes

Mental retardation

Yes

Dementia / Alzheimer's

Yes

Fainting spells

Yes

Visual impairment

Yes

Glaucoma

Yes

Hearing impairment

Yes

Gastrointestinal/Genitourinary:

Hepatitis (A, B, C, D, E)

Yes

Kidney dialysis

Yes

Ulcers

Yes

Sexually Transmitted Disease

Yes

Not permitted to give blood

Yes

Explain:

History of hospitalization/Surgical procedures:

Medications:

Are you taking any prescription medications, any over the counter items and/or herbal medicines at this time? If so please list them and the dose you use:

Yes

Dose:

Endocrine/Hematologic/Oncologic/Immune:

Frequent hunger

Yes

Frequent thirst

Yes

Diabetes

Yes

Thyroid disease

Yes

Hemophilia

Yes

Sickle Cell disease

Yes

Bleeding tendency

Yes

Anemia

Yes

Cancer

Yes

Radiation therapy

Yes

Chemotherapy

Yes

HIV infection/ AIDS

Yes

Organ transplant

Yes

Blood transfusion

Yes

Psychological:

Anxiety/Nervousness

Yes

Depression

Yes

Mental health treatment

Yes

Insomnia

Yes

Musculoskeletal/CNS/Developmental:

Chronic jaw and facial pain

Yes

Chronic headaches

Yes

Chronic neck pain

Yes

Popping or clicking of jaw

Yes

Joint replacement

Yes

Osteoarthritis

Yes

Rheumatoid arthritis

Yes

Spinal cord injury

Yes

Seizures

Yes

Dizziness

Yes

Weakness

Yes

Respiratory:

Asthma

Yes

Chronic sinus problems

Yes

Night sweats

Yes

Emphysema

Yes

Tuberculosis

Yes

Other:

Social:

Do you use tobacco products? If, Yes, how much?

Yes

Do you drink alcohol? If, Yes, how much?

Yes

Medication Allergy or Intolerance:

Penicillin

Yes

Dental anesthetic (Novocain)

Yes

Aspirin

Yes

Codeine

Yes

Latex products

Yes

Iodine

Yes

Other:

Do you have any medical conditions not already mentioned?

Do you or have you used bisphosphonate medication (i.c. Fosamax®, Actonel®, Boniva@,Skelid®, Didronel®, Aredia®, Zometa®, Bonefos®) to prevent or treat Osteoporosis or as part of cancer treatment?

Yes

Other:

Does the amount of saliva in your mouth seem to be too little?

Yes

Docs your mouth feel dry when cating a meal?

Yes

FEMALES ONLY:

Are you pregnant now? If Yes, How many months?

Yes

Are you breastfeeding? Do you take birth control?

Yes

Family History:
Did a parent, sibling or child of yours have any of the following?

Diabetes

Yes

High blood pressure

Yes

Heart disease

Yes

Bleeding tendency

Yes

Cancer

Yes

Patient's Primary Care Physician's Name and Phone Number:

Patient's Pharmacy Name and Phone Number;

Emergency Contact Name and Phone Number:

Emergency Contact relationship with Patient:

To the best of my knowledge, all of the preceding answers are true. If I have any change in my health status, or any change in my medicines, I will inform my dental health care provider at my next appointment.

Signature of Patient/Legal Guardian

Doctor's Signature

Date:

MM slash DD slash YYYY

2715 Loganville Hwy., Suite 340
Loganville, GA 30052

(678) 956-1381

Mon - Thu: 9:00 AM - 5:00 PM
Fri - Sun: Closed

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Streamline Your Dental Visits

Personal

Address and Home Phone

INSURANCE POLICY 1

Insurance Policy 2

MEDICAL HISTORY QUESTIONNAIRE

(678) 956-1381

(678) 956-1381

Site Links

Business Hours