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Patient Forms

Thank you in advance for the trust you have placed in our office. Below is a downloadable version for new patients forms. Please print them, fill them out and bring them with you to your first appointment. This will allow us more time to devote to your dental needs.

Please call the office if you have any questions. We are looking forward to meeting you.

View PDF Forms

Welcome
HIPPA
Office Policies

Or if you prefer, you can complete the forms online.
Your data will arrive in an email from our office.

This field is completed by the clinic

Patient #

SS#/SIN

Fecha

Name

Fecha 2

Home Phone

Address

City

State/Province

ZIP/P.C

Email

Cell Phone

Check appropriate box:

Status

Minor Single Married Divorced Widowed Separated

If student, name of school/college

City

State/Province

Time

Full time Part time

Patient or parent/Guardian's employer

Work phone

Address

City

State/Province

ZIP/P.C

Spouse or parent/Guardian's name

Employer

Work phone

Whom may we thank for referring you?

Person to contact in case of emergency

Phone

RESPONSIBLE PATIENT

Name of person responsible of this account

Relationship to patient

Address

Home phone

Email

Cell phone

Driver's licence number

Date

Financial institution

Employer

Work phone

SS#/SIN

Is this person currently a patient in our office?

Yes No

For you convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

Cash Personal Check VISA MasterCard I wish to discuss the office's payment policy

Name of Insured

Relationship to patient

Fecha

SS#/SIN

Fecha 2

Name of employer

Union or local #

Work Phone

Address of employer

City

State/Province

ZIP/P.C

Insurance company

Group #

Policy/ID#

Insurance company address

City

State/Province

ZIP/P.C

How much is your deductible?

How much have you used?

Max. annual benefit

DO YOU HAVE ANY ADDITIONAL INSURANCE?

Yes No

Name of Insured

Relationship to patient

Fecha

SS#/SIN

Fecha 2

Name of employer

Union or local #

Work Phone

Address of employer

City

State/Province

ZIP/P.C

Insurance company

Group #

Policy/ID#

Insurance company address

City

State/Province

ZIP/P.C

How much is your deductible?

How much have you used?

Max. annual benefit

Physician

Office phone

Date

1. Are you under medical treatment now?

Yes No

2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? If yes, please explain.

2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes No

Explain

3. Are you taking any medication(s) including non-prescription medicine? If yes, please list the medication(s).

3. Are you taking any medication(s) including non-prescription medicine?

Yes No

Medications

4. Have you ever taken Fen-Phen/Redux?

Yes No

5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?

Yes No

6. Have you ever taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?

Yes No

7. Do you use tobacco?

Yes No

8. Do you use controlled substances?

Yes No

9. Do you have or have you had any of the following?

High Blood Pressure

Yes No

Heart Attack

Yes No

Rheumatic Fever

Yes No

Swollen Ankles

Yes No

Fainting / Seizures

Yes No

Asthma

Yes No

Low Blood Pressure

Yes No

Epilepsy / Convulsions

Yes No

Leukemia

Yes No

Diabetes

Yes No

Kidney Diseases

Yes No

AIDS or HIV Infection

Yes No

Thyroid Problem

Yes No

Heart Disease

Yes No

Cardiac Pacemaker

Yes No

Heart Murmur

Yes No

Angina

Yes No

Frequently Tired

Yes No

Anemia

Yes No

Emphysema

Yes No

Cancer

Yes No

Arthritis

Yes No

Joint Replacement or Implant

Yes No

Hepatitis / Jaundice

Yes No

Sexually Transmitted Disease

Yes No

Stomach Troubles / Ulcers

Yes No

Chest Pains

Yes No

Easily Winded

Yes No

Stroke

Yes No

Hay Fever / Allergies

Yes No

Tuberculosis

Yes No

Radiation Therapy

Yes No

Glaucoma

Yes No

Recent Weight Loss

Yes No

Liver Disease

Yes No

Heart Trouble

Yes No

Respiratory Problems

Yes No

Mitral Valve Prolapse

Yes No

Others

10. Are you wearing contact lenses?

Yes No

11. Are you allergic to or have you had any reactions to the following?

Yes No

Local Anesthetics (e.g. Novocain) Penicillin or any Other Antibiotics Sulfa Drugs Barbiturates Sedatives lodine Aspirin Any Metals (e.g. nickel, mercury, etc.) Latex Rubber

Others

12. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Yes No

13. Women only. Are you a woman?

¿Are you a woman?

Yes No

Are you pregnant or think you may be pregnant?

Yes No

Are you nursing?

Yes No

Are you taking oral contraceptives?

Yes No

PATIENT DENTAL HISTORY

Name of previous dentist

Location

Date

1. Do your gums bleed while brushing or flossing?

Yes No

2. Are your teeth sensitive to hot or cold liquids/foods?

Yes No

3. Are your teeth sensitive to sweet or sour liquids/foods?

Yes No

4. Do you feel pain to any of your teeth?

Yes No

5. Do you have any sores or lumps in or near your mouth?

Yes No

6. Have you had any head, neck or jaw injuries?

Yes No

7. Have you ever experienced any of the following problems in your jaw?

Yes No

Clicking Pain (joint, ear, side of face) Difficulty in opening or closing Difficulty in chewing

8. Do you have frequent headaches?

Yes No

9. Do you clench or grind your teeth?

Yes No

10. Do you bite your lips or cheeks frequently?

Yes No

11. Have you ever had any difficult extractions in the past?

Yes No

12. Have you ever had any prolonged bleeding following extractions?

Yes No

13. Have you had any orthodontic treatment?

Yes No

14. Do you wear dentures or partials?

Yes No

15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Yes No

16. Do you like your smile?

Yes No

Quick appointment request

Appointments are not confirmed until the office reaches out to confirm your information. f you have any questions, please contact us here.

Full name

Telephone contact

Email

Select date

Select time

I have read and accept the privacy policies

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Contact

3823 N Econlockhatchee Trail,
Orlando, FL 32817
(321) 972-8312
Mon. – Fri. 8AM – 5PM | Sat. 8AM – 3PM

Links

Preventive & Diagnostic
Periodontal Treatments
Endodontic treatments (Root Canal)
Cosmetic surgeries
Restorative Treatments

Simple, surgical, and wisdom teeth extractions
Cosmetic treatments
Implants
Conventional orthodontics or Invisalign

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