New Patient Form

Please complete our New Patient Form prior to your appointment.

If you have any questions or concerns, feel free to contact the office at 617-209-2378 and we will be happy to assist you.

We look forward to welcoming you to The Belmont Dental Group family.

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Date

Who may we thank for this referral?

Patient Name

Your Name(Required)

First Last

Your Address

Street Address Address Line 2 City ZIP Code

Phone

Birthday

Gender

Male

Female

Marital Status

Married

Single

Divorced

Widowed

Occupation

If Minor, List Parent's Names

Mother

First Last

Father

First Last

Insurance

If you would like us to file insurance claims on your behalf, please provide us with the following information. Otherwise, payment is the patient's responsibility on the day of service. Thank You.

Do you have dental insurance?

Yes

Name of Insurance Company

Dental Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Name of Policy Holder

First Last

Social Security Number

Subscriber ID #

Birthdate

Employer

Group ID

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer Phone

Relationship to Patient

Emergency Information

Name

First Last

Relationship

Phone

Complete Address

Street Address Address Line 2 City State ZIP Code

Getting to know you

Is another member of your family a patient in our practice?

Yes

Name (if yes)

First Last

When was the last dental visit?

When was the last time you had dental x-rays?

Former Dentist:

Why did you select our office?(Required)

Medical History

Have you been under the care of a medical doctor during the past two years?

Yes

If yes, please explain:

Name of Physician

Physician Phone Number

Physician's Address

Street Address Address Line 2 City State ZIP Code

Have you ever been hospitalized?

Yes

Are you allergic to or made sick by:

Penicillin

Asprin

Codeine

Other

If other, please explain:

Have you ever had excessive bleeding requiring special treatment?

Yes

Check any of the following which you have had or have at present:

Are you having dental problems at this time?

Yes

If yes, please explain

Do you feel very nervous about having dental treatment?

Yes

Do you take pre-medication before dental treatments?

Yes

If yes, what do you take?

List all medications you are taking at this time:

Are you a smoker?

Yes

Do you have trouble getting numb for dental work?

Yes

When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, or shortness of breathe or because you are very tired?

Yes

Do you ankles swell during the day?

Yes

Women: Are you pregnant?

Yes

If yes, when are you due?

Are you taking any birth control pills?

Yes

Do you have any disease, condition or problem not listed? If so, please list:

How do you feel about getting and maintaining a healthy mouth?

How do you feel about the appearance of your teeth?

If you could changea anything about your smile, what would you change?

For All Patients

Patient Name (Parent if minor)

Relatioship

Date

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