New Patient Information

Thank you for choosing the Dental Implant Institute. Prior to your dental appointment, please answer the questions below.  
If you do not answer a Yes/No question, then your answer is a "NO" by default.

Patient Contact Information

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How did you hear about us?
 

Emergency Contact Information

Patient Insurance Information

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Medical History

For Women

Reason(s) for seeing the dentist today

Diseases or Medical Problems

Heart and Circulatory Problems

Please select all the problems that apply.
 

Breathing/Lung Problems

Please select all the problems that apply.
 

Stomach Problems

Mental Health Problems

Muscle and Bone Problems

Liver Problems

Neurologic Problems

Blood Problems

Please select all that apply
 

Other Problems

Please select all that apply
 

Allergies

Please select all that apply
 

H.l.P.A.A. NOTICE OF PRIVACY PRACTICES

H.I.P.A.A SIGNATURE *
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GENERAL CONSENT

GENERAL CONSENT SIGNATURE *
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WELCOME TO OUR OFFICE

WELCOME TO OUR OFFICE SIGNATURE *
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PATIENT BILL OF RIGHTS AND PATIENT RESPONSIBILITIES

PATIENT BILL OF RIGHTS AND PATIENT RESPONSIBILITIES SIGNATURE *
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ALL PATIENT FORMS & CONSENTS CONFIRM AND SUBMIT

I understand that the information I have given today is correct to the best of my knowledge. I also understand that the information will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I authorize the dental staff to perform any additional dental services that I may need during diagnosis and treatment with my informed consent. *
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