Patient Forms | Teche Dental

Patient Forms

We're excited to meet you! Please take a few minutes to fill out our New Patient Form. You can fill out the online form to the right, or you can click here to download a PDF of our forms.

If you have any questions, we're happy to help you! Just contact our office.

Please note that this form does time out after 20 minutes, please complete in one sitting.

Title First Name Last Name Date Address City State ZipCode Country Home Phone Number Work Phone Number Mobile Phone Number Email Sex Birthdate Marital Status Employer Work Address City State Zip code Occupation Whom may we thank for referring you to our office? In case of emergency who should be notified? Emergency Contacts Phone Number Person Responsible for payment Relation to patient Responsible party's birthdate Responsible party's address (if different from patient) Responsible party's City Responsible party's State Responsible party's Zipcode Responsible party's Phone Number Insurance Company Contract Group Subscriber # Subscriber Name Relation to patient Subscriber's Birthdate Subscriber Address (if different from patient) Subscriber Home Phone Number Subscriber Day Time Number Secondary Insurance Company Secondary Group # Secondary Subscriber # Reason for Today's Visit Former Dentist Patient Address Patient City Patient State Patient Zipcode Date of last dental care Date of last dental x-rays Check if you have any of the following: How often do you brush? How often do you floss? Physician' Name Date of Last Visit Have you had any serious illnesses or operations? If yes, describe Have you ever had a blood transfusion? If yes, give approximate dates Are you Pregnant? Nursing? Taking Birth Control? Check if you have had any of the following: Medications Allergies I agree to the statement above