Patient Information

If Student

Dental Insurance Information:

Do you have any additional insurance? If so, please complete the following section

Patient Dental History:

Do your gums bleed while brushing or flossing?

Do you have frequent headaches?

Are your teeth sensitive to hot or cold liquids/food?

Do you clench or grind your teeth?

Do you feel pain in any of your teeth?

Have you ever had any prolonged bleeding following extractions?

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

Do you wear dentures/partials?

Do you have a concern with snoring?

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




Do you like your smile?

Have you ever had orthodontic treatment?

Have your teeth shifted since?

Signature of Patient, Parent or Guardian:

Signature of patient/responsible party certifies that you have read and completed the above information to the best of my knowledge. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.