New Patient Form

Holt Family New Patient Form

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
Date Format: MM slash DD slash YYYY
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Patient information