New Patients Form

Full Name

Preferred Name

Contact Number

Please enter a valid phone number.

Email Address

Address

Date of Birth

Gender

Male

Female

I prefer not to say

I authorize contact from Duo Dental via email/text message (Including Appointment Reminders, Product Information and Promotions)

Yes

Preferred Method of Contact

Phone Call

E-mail

Text / SMSHow did you hear about us?FriendWalk ByGoogleFacebookReferralWho Can we Thank for Referring you?

Insurance

Insured Persons Name

Insured BirthdateInsurance CarrierEmployerPolicy/Group #Insured ID/Certificate #I authorize Duo Dental to submit claims electronically on my behalf. I assign my benefits and authorizepayment directly Duo Dental.

Yes

Dental History

Name of Previous Dentist

When was your last dental visit?

When did you last have dental x-rays?

How Often do you brush your teeth?

1x day

2x day

3x day

Other

Do you use a manual toothbrush or electric toothbrush?

Manual

Electric

How often do you floss your teeth?

List any other oral hygiene measures you use: (e.g. rinses, waterpik)

Do your gums ever bleed?

Yes

NoIf so, where?

Do you have any discomfort in your mouth?

Yes

NoIf so, where?

Do you feel you have bad breath?

Yes

Have you ever had dental implant surgery?

Yes

NoIf so, where?

Have you ever had orthodontic (braces) treatment?

Yes

Are you interested in straightening your teeth with Clear Aligner - Invisalign?

Yes

Are you interested in whitening your teeth?

Yes

Do you have sensitive teeth?

Yes

Are you happy with your smile?

Yes

Please list any concerns you may have

Medical History

The following information is required to enable us to provide you with the best possible dental care.All information is strictly private. We will review the questions and explain any you do notunderstand. Please fill in the entire form.

Name of Physician

Physicians Phone Number

Please enter a valid phone number.

Emergency Contact Name

Emergency Contact Phone Number

Please enter a valid phone number.

Drug Allergies*

Are you taking any medications, non-prescriptive drugs or herbal supplements of any kind? Please list

Have you ever been advised to take antibiotics prior to dental work for a heart murmur,mitral valve prolapse, rheumatic fever or for an artificial joint?

Yes

NoIf yes, Please Specify

List any medical conditions you are being treated for

Do you have or have you ever had

Aids

Asthma

Arthritis

Autoimmune Disorder

Blood Disorder

Cancer

Diabetes

Epilepsy

Heart Problems

Herpes

Hepatitis

High Blood Pressure

HIV

Jaundice

Leukemia

Liver Disease

Lung Disease

Kidney Disease

Pacemaker

Osteoporosis

Stroke

Tuberculosis

Thyroid Disease

UlcersAny Conditions not listed above

Do you smoke?

Yes

NoIf yes, how many per day or week?

Are you pregnant?

Yes

NoDue Date

Consent to Treatment and Office Policy

I authorize the doctor upon consultation and direct consent from the patient/parent/guardian to perform diagnostic procedures, treatment, x-rays and medication in the connection with the patient’s dental needs.

AcceptI understand that the responsibility for payment of dental services, including insurance or otherwise, is due and payable at the time of services rendered and despite any dental insurance I am ultimately responsible for any fees withheld by the insurance company.

AcceptTo the best of my knowledge all of the preceding answers are true and correct. If there are any changes I will without fail inform the Duo Dental at my next appointment.

AcceptI understand that I must provide 48 business hours to cancel or reschedule my appointments to avoid any fees.

AcceptI confirm I am the Patient or Parent or Guardian of the person listed in the form

AcceptSigned Date

Thank you! Your submission has been received!

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