New Patient Form @ Starsmileslv

Home
New Patients
Services
About
FAQ
Contact

Contacs Us:

702.639.3515 - North Las Vegas
702.270.3047 - Southwest Las Vegas

Appointment Form
New Patient Form

New Patient Form

Please enter the following information into the form, and press the "Submit" button at the bottom of the page. (*) indicates a required field

Patient's Name:*
FirstLast
Gender:*
- Male
- Female
Email:*
Address:*
Street AddressAddress Line 2CityStateZip Code
How long at this address:
Home Phone:*
Birth Date (MM/DD/YYYY):*
Age:*
Is patient is a minor?:
- Yes
- No
If patient is a minor, give parent's or guardian's name: *
Parent's or Guardian's Employer:
Parent's or Guardian's Work Phone:
Parent's or Guardian's Occupation:
Time here (Parent's or Guardian's work history):
Spouse Name:
FirstLast
Spouse's Birth Date (DD/MM/YYYY):
Spouse Employer:
FirstLast
Spouse Occupation:
Time here:
Whom may we thank for referring you to our office?:
Is this your:
Responsible Party / Billing Information
Responsible Party Name:
FirstLast
Address:
Street AddressAddress Line 2CityStateZip Code
How long at this address:
Home Phone:
Work Phone:
Birthdate (MM/DD/YYYY):
Relationship to patient:
Employer:
Occupation:
Time here:
Spouse Name:
FirstLast
Spouse Birthdate (MM/DD/YYYY):
Spouse Employer:
Spouse Occupation:
Time here (Spouse's work history):
Dental Insurance Information
Insured's Name:
FirstLast
Insured's Birthdate
Insured's Employer:
Dental Insurance Company:
Group Number:
Insurance Phone:
Address:
Street AddressAddress Line 2CityStateZip Code
Do you have dual coverage?:
- Yes
- No
Insured's Name:
FirstLast
Insured's Birthday:
Insured's Employer:
Dental Insurance Company:
Group Number:
Insurance Phone:
Address:
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Medical History
Patient's primary care physician:
Physician's Phone:
How would you describe your child's overall health?:
When was the child's last physical?:
Has your child been hospitalized under a physician's care in the last two years?
- Yes
- No
If so, why?:
Is your child currently taking any medications?:
- Yes
- No
If so, please list each medication:
Has your child ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic.)
- None
- Aspirin
- Codeine
- Erythromycin
- Iodine
- Latex
- Novocaine
- Nitrous Oxide
- Penicillin
- Sulfa Drugs
- Tetracycline
- Valium
- Xylocaine
- Other
If others, please explain:
Has the patient ever had any of the following? (Please check all that apply):
- None
- Arthritis or Gout
- Artificial Joint
- Asthma or Allergies
- Bleeding Problem or Anemia
- Blood disease
- Blood Transfusion
- Bruise Easily
- Cancer
- Cold Sores
- Congenital Heart Problems
- Currently Pregnant
- Diabetes
- Dizziness or Fainting
- Drug/Alcohol Addiction
- Eating Disorder
- Emphysema
- Epilepsy or Seizures
- Fever Blisters
- Frequent Thirst
- Frequent Urination
- Glaucoma
- Heart Attack or Stroke
- Heart
Murmur
- Heart Trouble
- Heart Valve or Pacemaker
- Hepatitis (A)
- Hepatitis (B)
- Hepatitis (C)
- Herpes
- High/Low Blood Pressure
- HIV-AIDS-ARC
- Hypoglycemia
- Jaw Joint Pain
- Kidney or Liver Disease
- Lung Disease
- Psychiatric Care
- Radiation/Chemotherapy
- Rheumatic Fever
- Sinus Problems
- Thyroid Problems
- Tuberculosis
- Tumor or Growth
- Ulcers or G.I. Problems
- Use Tobacco
- X-ray/Chemotherapy
Does your child have any condition or problem not listed which we should know about? Please explain:
Has your child ever been given antibiotics before dental treatment?:
- Yes
- No
Dental History
Reason for this visit?:
Is this your child's first dental visit?:
- Yes
- No
If no, date of last visit (MM/DD/YYYY):
Date of last e-ray (MM/DD/YYYY):
Work done:
Name of former dentist:
Phone:
Type of dentist:
Was your child breast fed?:
- Yes
- No
- Currently
If yes, until what age?
Was your child bottle fed?:
- Yes
- No
- Currently
If yes, until what age?:
Has your child ever had any injuries to his or her teeth, mouth, head or jaws?:
- Yes
- No
If yes, please describe:
Does your child brush daily?:
- Yes
- No
Does an adult assist with brushing?:
- Yes
- No
Does your child floss?:
- Yes
- No
Does an adult assist with flossing?:
- Yes
- No
Does your child have any of the following mouth habits:
- None
- Finger Sucking
- Mouth Breathing
- Teeth Grinding
- Lip Sucking
- Nail Biting
- Pacifier
- Tongue Thrusting
- Other
If other, please explain:
Does your child receive fluoride in any of the following forms:
- Vitamins
- Water Supply
- Tooth Paste
- Tablets/Drops
- Rinse/Gel
- Other
If other, please explain:
Has your child had any bad dental or medical experiences in the past?:
- Yes
- No
If yes, please explain:
Please check any of the following that may describe your child:
- Outgoing
- Cooperative
- Shy
- Mellow
- Anxious
- Curious
- Hyper
- Stubborn
- Defiant
- Friendly
- Trusting
- Moody
- Suspicious
Child's interests:
Favorite sport:
Favorite movie:
How can we make this a more positive experience for your child?:
Nearest Relative
Name of nearest relative not living with you?:
FirstLast
Phone:
Address:
Street AddressAddress Line 2CityStateZip Code

Name
Phone
Email*
Referred by
Comment

2011 Dr. Wilson Dental. All Rights Reserved. Design by Adlava