Menu HomeServicesPreventive CareAbout Us Meet The Doctors Meet Our TeamSmile GalleryFormsDental Care MembershipBlogContact Us New Patient Form Patient InformationName* First Middle Last Address* Street Address City State / Province / Region ZIP / Postal Code Date of Birth* MM slash DD slash YYYY Gender*MaleFemaleMarital Status*MarriedSingleWidowedDomestic PartnershipHome Phone*Work Phone*Cell Phone*Email* Social Security #* How Would you like to receive appointment reminders?*Phone CallEmailTextEmployer* Employer Phone*Primary Dental CarrierSubscriber Name Social Security # Date of Birth MM slash DD slash YYYY Employer Insurance Company Insurance Co PhoneGroup # Relation to Patient Is this patient under 18? Yes, this patient is under 18 Responsible Party Relation to Patient Address PhoneSecondary Dental CarrierSubscriber Name Social Security # Date of Birth MM slash DD slash YYYY Employer Insurance Company Insurance Co PhoneGroup # Relation to Patient Is this patient under 18? Yes, this patient is under 18 Responsible Party Relation to Patient Address PhoneHealth HistoryPlease use the checkboxes below to indicate if you have had any of the following.Conditions Abnormal Bleeding Alcohol Abuse Allergies Anemia Angina Pectoris Arthritis Artificial Heart Valve Asthma Blood Transfusion Cancer Chemotherapy Colitis Gongenital Heart Defect Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Facial Surgery Fainting Spells Fever Blisters Frequent Headaches Glaucoma HIV AIDS Heart Attack Heart Murmur Heart Surgery Hemophilia Hepatitis A Hepatitis B Hepatitis C High Blood Pressure Joint Replacement Kidney Problems Liver Disease Low Blood Pressure Mitral Valve Prolapse Pace Maker Psychiatric Problems Radiation Therapy Rheumatic Fever Seizures STD's Shingles Sickle Cell Disease Sinus Problems Stroke Thyroid Problems Tuberculosis Ulcers Allergies Aspirin Codeine Dental Anesthetics Erythromycin Latex Metals Penicillin Sulfa Tetracycline Other: Do You Smoke?*NoYesIf Female:Are You Taking Birth Control?*NoYesAre You Pregnant?*NoYesIf Yes, # Of Weeks: Are You Nursing?*NoYesMedications:List any medications you are currently taking and why:Dental EvaluationIs there anything about your smile that you don't like?* Do you have any missing teeth?* Is your bite conformatable for chewing, biting?* Do you have any old fillings or dental work that you don't like?* Would you be interested in enhancing your smile with whiter, more aligned teeth?*NoYesIf nervous, would you like to have your dentistry done with laughing gas (Nitrous Oxide)?*NoYesIs there anything about your mouth that concerns you now?*NoYesIf yes, please explain:How long has it been since you have seen a dentist? For what reason?*Were X-Rays taken at this last visit?*NoYesHave you ever had orthodontic treatment?*NoYesDo you use dental floss, toothpicks?*NoYesHave you ever had wisdom teeth removed?*NoYesDo your gums ever bleed?*NoYesAre any of your teeth loose?*NoYesDo you have any swelling, sores or blisters in your mouth?*NoYesHave you ever been told that you have Gum Disease?*NoYesHave you ever visited a Periodontist (Gum Specialist)?*NoYesDo you feel you have unpleasant breath at times?*NoYesAre you interested in using sedatives while dental treatment is being performed?*NoYesHow would you describe your dental health on a scale of 1-10 (with 10 being the best)?*12345678910Is there anything else we should know about? Have you had any prior dental experiences that were not pleasant? Is there anything that we can do to make your dental visits more comfortable?*This check box is your signature and by checking it you agree that all the information contained within this form is true and accurate. And that you give Matthew Cilderman DDS & Associates permission to use this information for internal purposes and when working with your insurance company.* Check to Agree Are you ready to get started? Schedule an Appointment
