New Patient Form

To become a new patient of Premier Dental of St George, fill out the information below:

Patient Information

First Name

Last Name

Middle Initial

Gender *

Male

Female

Family Status *

Married

Single

Child

Other

Date *

Format: MM/DD/YYYY

SSN *

Birth Date *

Format: MM/DD/YYYY

Phone (Home) *

Phone (Work)

Best time to call

Email Address *

Mailing Address *

Mailing Address

City

State/Province

Zip/Postal

Reason for this visit

Date of Last Dental Visit *

Format: MM/DD/YYYY

Have you ever had any of the following?

Please check all that apply

Allergies *

Pregnancy Due Date *

Tooth/Teeth Removal Details (Operation date, reason, etc.) *

Any fears or concerns *

For Women

Do you take Birth Control?

Yes

No

Are You Nursing?

Yes

No

Immunosuppressants or Osteoporosis Medication

Yes

No

Have you ever had any complications following dental treatment? *

Yes

No

If yes, please explain: *

Have you been admitted to a hospital or needed emergency care during the past two years? *

Yes

No

If yes, please explain: *

Are you now under the care of a physician or have you had any serious medical conditions? *

Yes

No

If yes, please explain: *

Name of Physician: *

Physician’s Phone Number: *

Do you have any health problems that need further clarification? *

Yes

No

If yes, please explain: *

Are you taking any prescription/over the counter drugs?

Do you snore or have sleep apnea? *

Yes

No

If yes, please explain: *

Agreement

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any changes in my health, I will inform the doctors at the next appointment without fail.

Signature of patient, parent or guardian *

Date *

Format: MM/DD/YYYY

Patient Information

Have you ever had any of the following?

For Women

Agreement

We Would Love To Meet You!

PREMIER ST GEORGE NEW PATIENTS

Premier Dental