New Patient Forms

Please take a minute to fill out the following secure patient forms before your first visit:

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Medical & Dental History

Health History Child

1. About Your Child

Child’s name:

Nickname:

Birthdate:

Age:

Sex:

Other

Preferred pronouns:

Home address:

City:

State:

ZIP:

Phone:

Email:

2. Accompanying Your Child Today

Name:

Relation:

Whom may we thank for referring you?

General dentist:

Last visit date?

Siblings?

DOB:

Siblings?

DOB:

Siblings?

DOB:

Parent’s marital status:

Single

Partnered

Married

Divorced

Widowed

Separated

3. Dental Insurance Information

Insurance company name:

Address:

City

State/Province

Zip/Postal

Adult Coverage?

Yes

Phone:

Subscriber:

SSN:

Subscriber Birthdate:

Group #:

4. Responsible Party #1

Name:

Address:

Phone #:

Employer:

Occupation:

Wk #:

Cell #:

Relationship to patient:

Responsible for account?

Appointments?

4. Responsible Party #2

Name:

Address:

Phone #:

Employer:

Occupation:

Wk #:

Cell #:

Relationship to patient:

Responsible for account?

Appointments?

5. Medical History

Your child’s current medical health is:

Good

Fair

Poor

Physician Name:

Phone:

Is your child under current care?

Is your child taking any prescription or over-the-counter drugs?

Please list each one:

Has your child reached puberty?

Has your daughter begun to menstruate?

Is your daughter pregnant?

If so, how many months along?

Has your child ever had any of the following diseases or medical problems?

Anemia

Artificial Bones / Joints / Valves

Arthritis

Allergies

Blood Transfusion

Cancer / Chemotherapy

Congenital Heart Defect / Heart Murmur

Diabetes

Difficulty Breathing / Asthma / Hayfever / Sinus

Epilepsy / Seizures / Fainting Spells

Fever Blisters / Herpes

Stroke or Heart Surgery

Hemophilia / Abnormal Bleeding

Hepatitis / Jaundice / Liver Problems

High / Low Blood Pressure

Immunocompromised

Hospitalized for any reason?

Kidney Problems

Mitral Valve Problems

Psychiatric Problems

Rheumatic / Scarlet Fever

Sever / Frequent Headaches

Sinus Problems

Radiation Treatment

Tonsils or Adenoids Removed:

Age:

Tuberculosis (TB):

Ulcers / Colitis:

Venereal Disease:

Sensory Processing Issues

Type:

6. Dental History

What are the main concerns that you would like to address?

Has your child been evaluated for or had orthodontics?

Have there been any injuries to your child’s face, mouth or chin?

Has your child been informed of any missing or extra permanent teeth?

Has your child ever had any pain or tenderness in his/her jaw joint (TMJ/TMD)?

Does your child floss his/her teeth daily?

How many times per day does your child brush?

Does your child have any of the following concerns?

Thumb/Finger Sucking

Lip Sucking/Biting

Clenching/Grinding Teeth

Nursing Bottle Habits

Mouth Breather

Speech Problems

Nail Biting

Tongue Thrust

Snoring at night

Sleep walking, nightmares, night terrors

Sleep talking, night sweats

Tiredness during the day or hyperactivity

Restless Sleep

Family history of sleep apnea

Who?

7. Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. This practice uses AI technology to assist with drafting patient communications and clinical documentation. AI is a support tool and all content is reviewed and approved by your care team before use. AI does not make clinical decisions. AI vendors are contractually prohibited from training on your data. Your information is protected under HIPAA. You may ask questions or opt out in writing at any time. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

My records may be used for teaching or research

Parent/Guardian Signature

Clear

Date

If you are human, leave this field blank.

Health History Adult

1. About You

Name:

I prefer to be called:

Birthdate:

Sex:

Other

Preferred pronouns:

Email address:

SSN:

Home address:

City:

State:

ZIP:

Marital Status:

Single

Partnered

Married

Divorced

Widowed

Separated

Home #:

Cell:

Employer:

Occupation:

Whom may we thank for referring you?

Other family members seen by us?

General dentist:

Last visit date:

2. Spouse Information

Name:

Occupation:

Employer:

Home #:

Cell:

Email:

3. Billing Information

Person(s) responsible for the account:

Billing address:

Relationship:

SSN:

4. Medical History

Do you have a personal physician?

Yes

Physician’s name:

Phone #:

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone #:

5. Insurance Information

Insurance company name:

Address:

City:

State:

ZIP:

Adult Coverage?

Yes

Phone

Subscriber:

SSN:

Subscriber Birthdate:

Group #:

6. Medical History

Your current medical health is:

Good

Fair

Poor

Are you currently under the care of a physician?

Please explain:

Are you taking any prescription or over-the-counter drugs?

Please list each one:

For Women:

Are you taking birth control pills?

Are you pregnant?

Weeks #:

Are you nursing?

Have you ever had any of the following diseases or medical problems?

Anemia

Artificial Bones / Joints / Valves

Arthritis/Osteoporosis/Bisphosphonates

Blood Transfusion

Cancer / Chemotherapy

Congenital Heart Defect / Heart Murmur

Diabetes

Difficulty Breathing / Asthma / Hayfever / Sinus

Epilepsy / Seizures / Fainting Spells

Fever Blisters / Herpes

Heart Attack / Stroke / Surgery / Pacemaker

Hemophilia / Abnormal Bleeding

Hepatitis / Jaundice / Liver Problems

High / Low Blood Pressure

Immunocompromised

Hospitalized for any reason?

Kidney Problems

Mitral Valve Problems

Psychiatric Problems

Rheumatic / Scarlet Fever

Severe / Frequent Headaches

Sinus Problems

Radiation Treatment

Tonsils or Adenoids Removed

Age:

Tuberculosis (TB)

Ulcers / Colitis

Venereal Disease

Sensory Processing Issues

Type:

Please list any serious medical condition(s) you’ve had:

Are you allergic to the following

Aspirin

Erythromycin

Metal / Plastics

Latex

Codeine

Penicillin

Anesthetics

Tetracycline

7. Dental History

Your current medical health is:

Good

Fair

Poor

What are the main concerns that you would like to address?

Have you ever had/been evaluated for orthodontics?

Do you now or have you ever experienced pain/ discomfort in your jaw joint (TMJ / TMD)?

Do you want to improve your smile?

Do your gums ever bleed?

Have you ever injured your

Mouth

Teeth

Chin

Do you have any speech problems?

Do you grind your teeth?

Do you generally breathe through your mouth?

Do you generally breathe through your mouth while asleep?

Do you snore or have restless sleep?

Do you experience excessive tiredness during the day?

Do you have a family member with sleep apnea?

Do you have any extra or missing permanent teeth?

Do you have more than one bite?

Do you have problems chewing gum?

Do you have problems chewing sticky/chewy foods?

Have your teeth changed in the last five years?

8. Authorization

My records may be used for teaching or research

Signature

Clear

Date

If you are human, leave this field blank.

Conveniently located at

95 Montgomery Dr #220, 
Santa Rosa, CA 95404.

Just minutes from Rohnert Park, CA and Windsor, CA