New Patient Form 0% Complete1 of 6 If you are human, leave this field blank. 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 * SSN * Birth Date * Phone (Home) * Phone (Work) Best time to call Email Address * Mailing Address * Mailing Address Mailing Address Mailing Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Country Reason for this visit Date of Last Dental Visit * Have you ever had any of the following? Please check all that apply Checkboxes AIDS Allergies (Enter Details Below) Anemia Arthritis Artificial Valves/Joints Asthma Blood Disease/Transfusion Cancer/Chemotherapy Diabetes Dizziness Epilepsy Excessive Bleeding Fainting/Epilepsy/Seizures Glaucoma Growths Hay Fever Head Injuries Heart Attack/Disease Heart Murmur Hepatitis A or B High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Pregnancy (Enter Details Below) Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Stroke Tuberculosis Tumors Ulcers Venereal Disease Codeine Allergy Penicillin Allergy Aspirin Allergy Erythromycin Allergy Tetracycline Allergy Dental Anesthetic Allergy Latex Allergy Sulfa Allergy Do You Use Tabacco ADD or ADHD Heart Surgery Sensitivity to Hot/Cold Previous Drug/Alcohol Abuse Sensitivity to Sweets Clicking of the Jaw Pain (Joint, Ear, Side of Face) Difficulty Chewing Difficulty Opening/Closing Have you had teeth removed? (Enter Details Below) Local Anesthetic Reactions Do you have fears of concern (Enter Details Below) Allergies * Pregnancy Due Date * Tooth/Teeth Removal Details (Operation date, reason, etc.) * Any fears or concerns * For Women: Do you take Birth Control? Are you nursing? 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? Have you taken Fosamax, Boniva, or any other drugs prescribed to decrease the resorption of bone as in osteoporosis or any drugs for metastatic bone cancer? * Yes No If yes, please explain: * 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 * Next Page
