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New Patient Form

Download or submit online

Home > New Patient Form

Download & Print

Download the printable New Patient Form bellow and bring the completed form to your appointment.

Questions?

Call 641-472-3147 if you have any questions at all.

Complete & Submit Online

Fill in the New Patient Form online.

Step 1 of 5

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Patient information
Please fill in the patient information
Name
First Last
Date of Birth*
Address
Street Address Address Line 2 City State ZIP Code
Email*
Social Security Number*
Phone*
Cell
Work
Emergency Contact
Who may we thank for referring you?

Responsible Party
Name of responsible party
First Last
Relationship to the patient
Phone
Cell
Address
Street Address Address Line 2 City State ZIP Code
Is this person currently a patient

Primary Dental Insurance
Name of Insured
First Last
Social Security Number
Date of Birth
MM slash DD slash YYYY
Relationship to the patient
Address
Street Address Address Line 2 City State ZIP Code
Name of Employer
Employer Address
Street Address Address Line 2 City State ZIP Code
Insurance Company Name
Insurance Company Address
Street Address Address Line 2 City State ZIP Code
Insurance ID
Group
Insurance Company Phone
Secondary Dental Insurance
(if applicable)
Name of Insured
First Last
Social Security Number
Date of Birth
MM slash DD slash YYYY
Relationship to the patient
Address
Street Address Address Line 2 City State ZIP Code
Name of Employer
Employer Address
Street Address Address Line 2 City State ZIP Code
Insurance Company Name
Insurance Company Address
Street Address Address Line 2 City State ZIP Code
Insurance ID
Group
Insurance Company Phone

Patient Medical History
Physician
First Last
Office Phone
Date of Last Exam
MM slash DD slash YYYY
Are you currently under care of a physician?*
Please Explain
Have you been hospitalized for any surgical procedures/serious ilnesses?*
Please Explain
Are you currently taking any medications, prescription or non prescription?*
Please list all medications, vitamins and supplements
Do you use tobacco products?*
Do you have any ARTIFICIAL JOINTS, IMPLANTS, HEART VALVES etc?*
Please Explain
Have you ever be told to premedicate before a dental appointment?*
If so, what medication?
Have you ever had any of the following? Please select ALL that apply!
- High blood pressure
- Low blood pressure
- Stroke
- Heart Murmur
- Diabetes
- Hepatitis
- Heart disease/Heart Attack
- HIV or AIDS
- Rheumatic Fever
- STD
- Chest Pain/Angina
- Cold Sores/Fever blisters
- Cancer
- Radiation Therapy
Cancer Type
Are you allergic to or had a reaction to any of the following? Please select ALL that apply!
- Local Anestethics
- Latex
- Penicillin/other antibiotics
- Codein
- Aspirin
- Other medications
Please list other allergies
Women only:
Are you pregnant or think you may be pregnant?
Are you nursing?
Do you take medication for Osteoporosis?

Dental History
Date of Last Dental Exam
Previous Dentist
First Last
Do your gums bleed while flossing/brushing?*
Are your teeth sensitive to hot, cold, sweet, or sour liquids/foods?*
Do you feel pain in your teeth?*
Do you have any sores or lumps in or near your mouth?*
Do you clinch or grind your teeth?*
Have you ever had head, neck or jaw injuries?*
I certify that I understand and have answered all questions to the best of my knowledge.
Signature: _______________________________
You may be required to sign this form at Holt Family Dental Care at your visit.
Date
MM slash DD slash YYYY

Holt Family Dental Care

106 E Washington Ave
Fairfield, IA 52556

(641) 472-3147
(641) 472-7465 (Fax)
facebook.com/HoltFamilyDental

Business Hours

Monday

8:00 AM — 5:00 PM

Tuesday

8:00 AM — 5:00 PM

Wednesday

8:00 AM — 5:00 PM

Thursday

8:00 AM — 5:00 PM

Friday

8:00 AM — 12:00 PM

Saturday

Closed

Sunday

Closed

Contact Us
Directions/Map
Common Questions
Financial Options
Refer a Friend
HALO-LED^(TM)
Privacy Policy
Disclaimer

Contact Us
Directions/Map
Common Questions
Financial Options
Refer a Friend
HALO-LED^(TM)
Privacy Policy
Disclaimer

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2024

by Holt Family Dental Care. All rights reserved.

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Contact Us

106 E Washington Ave
Fairfield, IA 52556