New Patient Forms

Hello, and welcome to Nuance Dental Specialists! 

To help ensure that your first appointment with us runs smoothly, please take a moment to fill out the forms below.  All information is secure, confidential, HIPAA compliant, and will not be shared with any outside sources.  

Personal Information
Name *
Name
Gender *
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Please Provide the Best Contact Number (Cell, Home, Office or Other)
Medical History (Confidential)
Have you visited your Primary Care Physician (PCP) within the last year? *
Are you presently being treated for any medical conditions? *
Are you currently taking any prescription or over-the counter medications? *
Do you use tobacco products? *
Do you drink alcoholic beverages? *
Primary Care Physician (PCP) *
Primary Care Physician (PCP)
PCP Address *
PCP Address
PCP Phone *
PCP Phone
CHECK ALL THAT APPLY
ALLERGIES *
CARDIOVASCULAR *
HEMATOLOGIC *
RESPIRATORY *
ENDOCRINE *
RENAL *
IMMUNE *
MUSCULOSKELETAL *
GASTROINTESTINAL *
HEPATIC *
NEUROLOGIC *
SKIN *
EYES / EARS *
INFECTIONS *
CANCER / CHEMOTHERAPY / RADIATION *
If you check "yes" please describe below.
PREGNANT / NURSING *
PREMEDICATION *
OTHER (Check All That Apply)
EMERGENCY CONTACT DETAILS
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
DENTAL HISTORY
Have you ever been examined or treated by a Prosthodontist? *
Have you ever received treatment from any of the following dental specialists? *
Is it important for you to keep your teeth? *
Are you satisfied with the appearance of your teeth? *
How long has it been since your last thorough dental examination and x-rays? *
Has the fear of discomfort kept you from regular dental visits? *
Do you experience bad breath or taste in your mouth? *