New Patient Form

"*" indicates required fields

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Patient Information

Today's Date*

MM slash DD slash YYYY

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Social Security Number

Date of Birth*

Month

Day

Year

Sex*

Male

Female

Employer*

Emergency Contact Name*

Phone*

How do you plan to settle your account?*

Please List*

Dental History

Are you having Dental Pain?*

Yes

Do you have difficulty eating?*

Yes

Are you interested in Dental Implants to stabilize dentures?*

Yes

When was your last Dental Visit?*

What are your main Dental concerns and what brings you in today?*

Health History

FOR THE FOLLOWING QUESTIONS, CIRCLE YES OR NO, WHICHEVER APPLIES. YOUR ANSWERS ARE FOR OUR RECORDS ONLY AND WILL BE CONSIDERED CONFIDENTIAL.

Are you in good health?*

Yes

Have you had any serious illnesses, operations or hospitalizations in the past five years?*

Yes

Last Physical Exam

Physician's Name

Physician Phone

Do you have, or have you had, any of the following?

AIDS/HIV Positive*

Yes

Alzheimer’s Disease*

Yes

Anaphylaxis*

Yes

Anemia*

Yes

Angina*

Yes

Arthritis/Gout*

Yes

Artificial Heart Valve*

Yes

Artificial Joint*

Yes

Asthma*

Yes

Blood Disease*

Yes

Blood Transfusion*

Yes

Breathing Problems*

Yes

Bruise Easily*

Yes

Cancer*

Yes

Chemotherapy*

Yes

Chest Pains*

Yes

Cold Sores/Fever Blisters*

Yes

Congenital Heart Disorder*

Yes

Convulsions*

Yes

Cortisone Medicine*

Yes

Diabetes*

Yes

Drug Addiction*

Yes

Easily Winded*

Yes

Emphysema*

Yes

Epilepsy or Seizures*

Yes

Excessive Bleeding*

Yes

Excessive Thirst*

Yes

Fainting Spells/Dizziness*

Yes

Frequent Cough*

Yes

Frequent Diarrhea*

Yes

Frequent Headaches*

Yes

Genital Herpes*

Yes

Glaucoma*

Yes

Hay Fever*

Yes

Heart Attack/Failure*

Yes

Heart Murmur*

Yes

Heart Pacemaker*

Yes

Heart Trouble/Disease*

Yes

Hemophilia*

Yes

Hepatitis A*

Yes

Hepatitis B or C*

Yes

Herpes*

Yes

High Blood Pressure*

Yes

High Colesterol*

Yes

Hives or Rash*

Yes

Hypoglycemia*

Yes

Irregular Heartbeat*

Yes

Kidney Problems*

Yes

Leukemia*

Yes

Liver Disease*

Yes

Low Blood Pressure*

Yes

Lung Disease*

Yes

Mitral Valve Prolapse*

Yes

Osteoporosis*

Yes

Pain in Jaw Joints*

Yes

Parathyroid Disease*

Yes

Psychiatric Care*

Yes

Radiation Treatments*

Yes

Recent Weight Loss*

Yes

Renal Dialysis*

Yes

Rheumatic Fever*

Yes

Rheumatism*

Yes

Scarlet Fever*

Yes

Shingles*

Yes

Sickle Cell Disease*

Yes

Sinus Trouble*

Yes

Spina Bifida*

Yes

Stomach/Intestinal Disease*

Yes

Stroke*

Yes

Swelling of Limbs*

Yes

Thyroid Disease*

Yes

Tonsilitis*

Yes

Tuberculosis*

Yes

Tumors or Growths*

Yes

Ulcers*

Yes

Venereal Disease*

Yes

Medications

Please list all medications (prescribed or over-the-counter)

Are you allergic to any medications?*

Yes

Please Select*

Please List

Are you taking or have you ever taken Bisphospho-nates for osteoporosis, multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa)*

Yes

Are you taking any anticoagulant/blood thinner (aspirin, Eliquis, etc)*

Yes

Have you recently stopped taking an anticoagulant/blood thinner*

Yes

For how long?

Are you taking Reflx/Proton pump inhibitors (eg Prilosec)*

Yes

Are you taking any SSRIs/Antidepressants (Prozac, Zoloft)*

Yes

Are you taking Beta blocker Blood pressure meds (end in -ol)*

Yes

Do you have an Autoimmune Disease (eg Lupus)*

Yes

Do you have Diabetes?*

Yes

Please list your HbA1c and Blood Glucose

Do you smoke or use other tobacco products?*

Yes

Do you Vape?*

Yes

Do you Dip?*

Yes

How many packs/cartridges per day?

Do you drink alcohol?*

Yes

How frequently?

Do you use marijuana or other "street" drugs?*

Yes

How frequently?

Do you get headaches or tooth aches in the morning from clenching or grinding?*

Yes

Other

Do you have any other disease, condition or problem not listed above that you think the doctor should know about?*

Yes

Do you wish to talk with the doctor privately about anything?*

Yes

Women

Are you pregnant, or could you be pregnant?*

Yes

Are you nursing?*

Yes

Are you taking birth control pills?*

Yes

I UNDERSTAND THE IMPORTANCE OF A TRUTHFUL HEALTH HISTORY TO ASSIST THE DOCTOR IN PROVIDING THE BEST CARE POSSIBLE. I HAVE HAD THE OPPORTUNITY TO DISCUSS MY HEALTH HISTORY WITH MY DOCTOR.*

Signature of person completing health history

FINANCIAL AGREEMENT

We believe it is important to provide affordable high quality Dental services. For your convenience, we accept MasterCard, Visa, American Express, and Debit Cards. We also offer Care Credit as a financing option. As it may be difficult to complete financial transactions following surgery and anesthesia, we respectfully request that your account be settled prior to your surgery. We are proud that our fees reflect the individualized service and care that we provide and hope that your experience exceeds your expectations.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have been offered a copy of the office’s Notice of Privacy Practices and have had the opportunity to discuss the policies with staff. Quality Dentures & Implants provides this form to comply with HIPAA requirements. Please review the Notice of Privacy Practices before signing this document.

By signing this form, you acknowledge that we may use and disclose your protected health information for treatment, payment, and healthcare operations. You have the right to request that we restrict how your protected health information is used or disclosed for treatment, payment and healthcare operations.

Signature of Patient or Legally Authorized Representative*

Date*

MM slash DD slash YYYY

Printed Name of Patient or Legally Authorized Representative*

First Last

Legal Relationship to Patient

I give permission for Quality Dentures & Implants to:*

Call/leave message at my home telephone number.

Call/leave message/text on my mobile number.

Call/leave message on my work number.

Send me an unencrypted email.

Other

Please List

I give permission for you to speak with these individuals about my care (Note: Please notify us if you wish to make a change in the future):

Name

Relationship

Phone Number

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Monday	8AM – 4PM
Tuesday	8AM – 4PM
Wednesday	8AM – 4PM
Thursday	8AM – 4PM
Friday	8AM – 12PM

Tooth Extractions

Full & Partial Dentures

Dental Implants

Tooth Extractions

Full & Partial Dentures

Dental Implants

New Patient Form

Patient Information

Dental History

Health History

Medications

Other

Women

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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Jacksonville, FL Office

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