NEW PATIENT FORM

We Look Forward To Meeting You!

Whether you are looking to book an appointment or have a dental health inquiry, our team is here to assist you. Please feel free to fill out the new patient form below or utilize one of the other contact methods listed below and a member of our staff will contact you in a timely manner.

If you would prefer to print the form and fill it out by hand, click the download button below

New Patient Form


Name:

Address:

Phone:

Email:

Birth Date:

Sex:

Marital:

Patient Social Security Number:

Student:

Emergency Contact:

Tell Us:


Do you have Dental Insurance?


Primary Insured

Insured Party:

Relationship to Insured Party:

Insured Party’s DOB:

Insured Party’s SSN:

Insured Party's Employer:

Insurance Company:

Insurance Company Phone:

* Please present PHOTO ID & INSURANCE CARD(s) to receptionist to be scanned into your chart. *


Health Information

Patient's Name:

Date of Last Medical Exam:

Physician’s Name:

Physician’s Phone:

Are you currently under medical treatment?

If yes, please explain:

Have you been hospitalized in the last 5 years?

If yes, please explain:

List all medications you are currently taking:

List all current and past health issues:

Anemia/Hemophilia, Arthritis, Asthma, Cancer, Cardiac Pacemaker, Chemical Dependency, Chest Pains/Angina, Congenital Heart Disease, Type II Diabetes, Easily Winded, Emphysema, Epilepsy/Seizures, Frequently Tired, Glaucoma, Hay Fever/ Allergies, Heart Attack, Heart Murmur, Heart Surgery, Hepatitis Type A, High Blood Pressure, HIV / AIDS, Joint Replacement/Date, Kidney Disease, Kidney Failure, Leukemia, Liver Disease, Low Blood Pressure, Mitral Valve Prolapse, Osteoporosis, Pneumonia, Psychiatric Disorder, Radiation Therapy, Recent Weight Loss, Recurrent Bronchitis, Respiratory Problems, Rheumatic Fever, Skin Disorders, Stomach/Intestinal Disease, Stroke, Swollen Ankles, Thyroid Problem, Tuberculosis, Venereal Disease


Are you ALLERGIC to or have you had ANY reaction to the following?

Aspirin:

Local Anesthetics:

Barbituates:

Metals: (Nickel, Mercury, etc.)

Codeine:

Sedatives:

Iodine:

Sulfa Drugs:

Any other allergies?

Any antibiotics you are taking? (list all)

Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing BISPHOSPHONATES?

Do you use tobacco?

Use alcoholic beverages?

Wear contact lens?

Use controlled substances?


LADIES ONLY:

Taking oral contraceptives?

Are you nursing?

Are you pregnant?

If so, when are you due?




Dental Information

What is the reason for your visit?

How often do you visit the dentist?

Date of last dental visit:

Date of last dental X-rays:

If you are wearing partials or dentures, what is the age of them?

How often do you brush?

How often do you floss?



Do your gums bleed while brushing or flossing?

Are your teeth sensitive to HOT/COLD?

Are your teeth sensitive to SWEET/SOUR?

Do you feel pain to any of your teeth?

Do you have any sores/lumps in or near your mouth?

Have you ever had any head, neck or jaw injury?



Have you ever experienced any of the following problems in your jaw?

Clicking?

Pain?

Difficulty opening/closing?

Difficulty chewing?

Do you have frequent headaches?

Do you clench/grind your teeth?

Do you bite your lips or cheeks frequently?

Any difficult extractions in the past?

Any prolonged bleeding following extractions?

Any orthodontic treatment?


Office Location

Visit the Berthelot Dental office today!

Berthelot Dental

6711 Highway 1 South Addis, LA 70710

Call Us To Schedule

We look forward to hearing from you!

Call Us Today!

225-364-3640

Send Us An Email

Send us an email with your questions.

We're Standing By!

info@berthelotdental.com