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New Patient Form

The responsible party must be 18 or older.


Responsible Party


Patient Information


Patient Information



Many of our services may be paid through medical insurance. This question is regarding only medical insurance, not dental benefits.

Please check ALL that apply!


Primary Medical Insurance

Many of our services may be paid through your medical insurance. These questions refer to MEDICAL insurance, not dental.

If you don't have the policy #, please enter the insured's social security #



Secondary/Supplemental Medical Insurance

These questions are regarding your secondary or supplemental MEDICAL insurance, not dental. That is coming up next, if applicable!



Primary Dental Benefits


 
Secondary Dental Benefits
Don't forget to bring your cards for your medical and dental benefits to your appointment.
 
Medical History

 
Dental History

Include dentists, physicians, chiropractors, therapists, etc.



Nearest Relative
 

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Have you already filled out new patient forms or are a current patient?
Fill out the TMD/TMJ and Headache Form.
TMD/Headache Questionnaire

TMD/Headache Questionnaire

First Middle Last



TMD/PAIN SYMPTOMS

Rank in order your symptoms starting from worst (#1)



SLEEP BREATHING COMPLAINTS

Continue ranking your symptoms with #1 being the worst




Symptoms
HEAD PAIN



JAW SYMPTOMS


MOUTH & NOSE RELATED CONDITIONS


EAR RELATED CONDITIONS

EYE RELATED CONDITIONS

THROAT, NECK AND BACK RELATED CONDITION


HEAD PAIN HISTORY

SEVERITY ON A SCALE OF 0 - 10

0 = No Pain 10 = Worst Pain Imaginable

0 = No Pain 10 = Worst Pain Imaginable

0 = No Pain 10 = Worst Pain Imaginable

0 = No Pain 10 = Worst Pain Imaginable


FREQUENCY & DURATION OF PAIN


Including dentists, orthodontists, ENTs, physicians, chiropractors, physical therapists, etc...




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