New Patient Form 0% Complete1 of 7 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 Aland Islands 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 Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara 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 Autoimmune Disease 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 Osteoporosis Thyroid Disease 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 Tobacco 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? 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 * Next Page If you are human, leave this field blank.
