Please fill out the New Patient Form below only after an appointment has been scheduled with our front desk staff.

Patient Information

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YOUR ADDRESS
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Birthdate
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Gender
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Relationship Status
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PATIENT EMPLOYMENT / SCHOOL
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  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
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  • Idaho
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  • New Hampshire
  • New Jersey
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  • New York
  • North Carolina
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  • Ohio
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  • Rhode Island
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  • West Virginia
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SPOUSE INFORMATION
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EMERGENCY CONTACT
Specify someone who does not live in your household
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Dental History

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  • Former Dentist State:
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
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Select "yes" or "no" to indicate if you have had any of the following:
Bad Breath
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Bleeding Gums
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Blisters on lip or mouth
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Burning sensation on tongue
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Chew on the side of mouth
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Cigarette, pipe or cigar smoking
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Clicking or popping jaw
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Dry mouth
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Fingernail biting
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Food collection between teeth
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Foreign objects
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Grinding teeth
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Gums swollen or tender
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Jaw pain or tiredness
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Lip or cheek biting
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Loose teeth or broken fillings
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Mouth breathing
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Mouth pain, brushing
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Orthodontic treatment
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Pain around the ear
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Periodontal Treatment
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Sensitive to cold
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Sensitive to heat
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Sensitive to sweets
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Sensitivity when biting
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Soars or growths in your mouth
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How often do you floss
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Health History

Physician's name
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Date of last visit
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Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. :
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Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)
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Select "yes" or "no" to indicate if you have had any of the following:
AIDS/HIV
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Anemia
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Arthritis, Rheumatism
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Artificial Heart Valves
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Artificial Joints
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Asthma
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Back Problems
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Bleeding abnormally, with extractions or surgery
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Blood Disease
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Cancer
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Chemical Dependency
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Chemotherapy
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Circulatory Problems
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Congenital Heart Lesions
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Cortisone Treatments
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Cough, persistent or bloody
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Diabetes
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Emphysema
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Do you wear contact lenses?
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Epilepsy
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Fainting or dizziness
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Glaucoma
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Headaches
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Heart Murmur
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Heart Problems
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Hepatitis
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Herpes
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High Blood Pressure
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Jaundice
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Jaw Pain
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Kidney Disease
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Liver Disease
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Low Blood Pressure
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Mitral Valve Prolapse
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Nervous Problems
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Pacemaker
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Psychiatric Care
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Radiation Treatment
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Respiratory Disease
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Rheumatic Fever
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Scarlet Fever
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Shortness of Breath
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Sinus Trouble
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Skin Rash
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Special Diet
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Stroke
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Swollen Feet or Ankles
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Swollen Neck Glands
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Thyroid Problems
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Tonsillitis
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Tuberculosis
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Tumor or growth on head or neck
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Ulcer
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Venereal Disease
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Weight Loss, unexplained
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Women:

Are you pregnant?
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Are you nursing?
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Taking birth control pills
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Select your due date
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Medications & Allergies

MEDICATIONS
List any medications you are currently taking and the correlating diagnosis:
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ALLERGIES - Select "yes" or "no" if you are allergic to any of the following:
Aspirin
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Barbiturates (Sleeping pills)
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Codeine
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Iodine
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Latex
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Local Anesthetic
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Penicillin
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Sulfa
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Sleep Questionnaire

Do you snore?
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Have you been told you stop breathing or gasp for air when sleeping?
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Have you awakened with your heart racing?
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Do you wake up often throughout the night?
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Do you wake up with headaches?
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Do you sweat at night?
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Do you wake up more than once to urinate?
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Do you wake up tired or often feel tired throughout the day?
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Have you recently gained weight or have difficulty losing weight?
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Do you suffer from acid reflux?
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Do you have high blood pressure or take medication for high blood pressure?
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Do you have heart disease?
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Do you have diabetes?
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Are you short tempered of get irritated easily?
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Do you smoke?
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Epworth Sleepiness Scale

Use the following scale to choose the most appropriate answer for each situation
0 = Would never fall asleep
1 = Slight chance of falling asleep
2 = Moderate chance of falling asleep
3 = High chance of falling asleep
Sitting and reading
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Watching TV
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Sitting inactive in a public place (e.g. a theatre or a meeting)
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As a passenger in a car for an hour without a break
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Lying down to rest in the afternoon when circumstances permit
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Sitting and talking to someone
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Sitting quietly after a lunch without alcohol
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In a car, while stopped for a few minutes in the traffic
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Thank you for choosing Dentistry at 1818 Market Street! Our primary mission is to deliver quality comprehensive dental care in a calming, friendly environment.

Please take a moment to review our office's financial and appointment policies.

  • We participate with most Dental Preferred Provider Organization (PPO) insurance plans. We will verify your benefits and submit to your insurance carrier as a courtesy; however it is the patient's responsibility to know their individual benefits (including limitations) and to pay for any services not covered by the insurance plan.
  • Patient copayments or payments for services not covered by insurance are due at the time of service. In the case of extensive treatment plans, payment arrangements can be made, but must be in place prior to treatment being rendered.
  • For your convenience, we do accept Visa, Mastercard, American Express, Discover, as well as cash, personal check or Care Credit (an independent financing company).
  • Flexible Spending Accounts/RSA Cards are treated as standard credit cards. It is the patient's responsibility to request/provide documentation for reimbursement.
  • We require 24 hour notice in regards to changes or cancellation of appointments. Appointments cancelled within 24 hours, or broken appointments will be subject to a $75.00 fee. In addition a 10 minute grace period is given for all appointments. If later than 10 minutes, the appointment will be rescheduled.
  • Retunred checks are subject to fee of $25.00
We hope that this will serve to clarify our policies and invite you to ask our staff any questions you may have. Accepting the terms in this form states that you are aware and compliant with all policies set forth by our office. We look forward to providing all your dental needs.


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