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NEW PATIENT FORM
oceancitydentists
2020-12-20T12:06:37-05:00
New Patient Form
Date
*
MM slash DD slash YYYY
SS/HIC/Patient ID#
Name
First
Last
Address
Street Address
Address Line 2
City
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
SEX
*
Male
Female
Age
Birthdate
*
Marital
Married
Widowed
Single
Minor
Seperated
Divorced
Partnered
How Many Years Partnered?
Patient Employer/School
Occupation
Employer/School Address
Street Address
Address Line 2
City
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer/School Phone
About your Spouse
Spouse's Name
Birthdate
SS#
Spouse's Employer
Whom may we thank for referring you?
Phone Numbers
Home Phone
work Phone
Other Phone
Spouse's Work Phone
Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
First
Last
Phone
Other Phone
Relationship
Dental History
Reason for today's visit
Former Dentist
City/State
Date of last dental visit
Date of last dental X-rays
Please check either YES or NO to indicate if you have had any of the following.
Bad breath
Yes
No
Food collection between the teeth
Yes
No
Orthodontic treatment
Yes
No
Bleeding gums
Yes
No
Foreign objects
Yes
No
Pain around ear
Yes
No
Blisters on lips or mouth
Yes
No
Grinding teeth
Yes
No
Periodontal treatment
Yes
No
Burning sensation on tongue
Yes
No
Gums swollen or tender
Yes
No
Sensitivity to cold
Yes
No
Chew on one side of mouth
Yes
No
Jaw pain or tiredness
Yes
No
Sensitivity to heat
Yes
No
Cigarette, pipe, or cigar smoking
Yes
No
Lip or cheek biting
Yes
No
Sensitivity to sweets
Yes
No
Clicking or popping jaw
Yes
No
Loose teeth or broken fillings
Yes
No
Sensitivity when biting
Yes
No
Dry mouth
Yes
No
Mouth breathing
Yes
No
Sores or growths in your mouth
Yes
No
Fingernail biting
Yes
No
Mouth pain, brushing
Yes
No
How often do you floss?
How often do you brush?
Thank you for filling out this form.
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