Please fill out the form below and then click the SUBMIT button.  This information is necessary for us to open a file for you prior to your visit.  After you submit the form, one of our representatives will contact you to discuss appointment options.

Patient Information

 

First Name
Middle Name
Last Name
How would you like to be addressed?
Address
City
State	Select Your State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Reason for visit?
Email Address
Employer
Occupation
Home Phone
Cell Phone
Work Phone
Date of Birth	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Age
Marital Status	Select Single Married Widowed Divorced
Spouse's Name (if married)

Emergency Contacts

 

Family Contact
Name
Relationship
Home Phone
Cell Phone
Non-Family Contact
Name
Relationship
Home Phone
Cell Phone
Are we allowed to give info to them?	Select Yes No

How did you learn about us?

 

Please choose and indicate which one if there is a box beside your choice	Magazine Internet   Yellow Pages   Patient Doctor Our web site   Another web site Friend Relative Other
May we use your name to thank them?	Select Yes No
May we call you at work?	Select Yes No
Can we leave a message for you at home?	Select Yes No
Can we email you at the address provided?	Select Yes No

Medical History

 

Are you allergic to anything?	Select Yes No
If yes, please list any allergy to medicine, serum or food and the type of reaction
Have you ever had local anesthesia for dental work or minor surgery?	Select Yes No
Please list any reactions you may have had to local anesthesia
Do you smoke?	Select Yes No
If so, how many packs per day?
Have you quit?	Select Yes No
How long ago?
Do you chew tobacco or Nicorette gum?	Select Yes No
Do you use nicotine patches?	Select Yes No
Your height
Your weight
List any medications you take regularly (please include the dosages)
List any operations you have had (please include types and dates)
List any serious illnesses or injuries
Other information the doctor should know
VERY IMPORTANT! Do you take Phen/Fen or any other diet medications?	Select Yes No

Family History

 

Has any member of your immediate family ever had any of the following?	Disease Relationship of Person to You Heart Disease Tuberculosis Diabetes Stroke Cancer Birth Defects
Have you ever had or do you now have any of the following?	Select Yes No General: birth defects, trauma Select Yes No Head & Neck: eye, ear, nose or throat trouble Select Yes No Lungs: allergies or asthma, shortness of breath, chronic cough Select Yes No Heart: chest pain, high or low blood pressure, rheumatic fever, bled excessively after injury or tooth extraction Select Yes No Skeletal: broken bones, amputated arm, leg, finger or toe, back trouble, rheumatism or arthritis Select Yes No Abdomen: stomach or intestinal problems, hepatitis or jaundice, kidney or bladder trouble, recent weight loss or gain Select Yes No Nervous system: headaches, dizziness, fainting, paralysis, head injury, seizures, nervous trouble of any sort Select Yes No Skin: skin disease, growth, tumor, cyst, cancer Select Yes No Mental illness: symptoms of mental illness or treatment for mental illness
	By checking this box, I affirm that I have informed the doctor of all my known allergies, previous surgeries and medications that I am taking or have recently taken, including prescriptions, over-the-counter remedies, herbal therapies and any other.

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