Read here about the new HALO-LED^(TM) system and other precautions our team has implemented in the interest of your continued health and safety.

Home
Our Services
Our Team
Contact Us

New Patient Form

Call Now 641-472-3147

Save time at your first appointment… Complete & submit the online form below.

Or download the printable New Patient Form here and bring the completed form to your appointment.

Call 641-472-3147 if you have any questions at all. We look forward to seeing you!

New Patient Form

Holt Family New Patient Form

Step 1 of 5

20%

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/low blood pressure
- Stroke
- Heart Murmur
- Diabetes
- Mitral Valve Prolapse
- 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
CAPTCHA

Contact Us

Telephone: 641-472-3147 • Fax: 641-472-7465

106 E Washington Ave Fairfield, IA

Michael E. Holt, D.D.S., Theresa I. Holt, D.D.S., Matthew W. Holt, D.D.S.

Business Hours

Monday8:00 AM — 5:00 PM

Tuesday8:00 AM — 5:00 PM

Wednesday8:00 AM — 5:00 PM

Thursday8:00 AM — 5:00 PM

Friday8:00 AM — 12:00 PM

SaturdayClosed

SundayClosed

New Patient Form

Contact Us

*
Name
Your Phone Number
Your E-mail
Your Message*
CAPTCHA

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

Copyright © 2015 Holt Family Dental Care. Developed by Hill Productions & Media Group, Inc.

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