Dental History Form

Patient Name: Last First Middle
What dental care would you like us to provide today?
Please select 'yes' or 'no' for the following questions:
Yes No Are you having PAIN, SWELLING, or SORE SPOTS at this time?
Yes No Do your gums bleed?
Yes No Have you had GUM TREATMENTS?
Yes No If you SNORE, would you like an oral device to help you stop snoring?
Yes No Do you have BAD BREATH?
Yes No Is this your FIRST VISIT to any dentist?
Yes No Have you had any COMPLICATIONS with dental treatment?
Yes No Have you been treated for TMJ (Temporomandibular joint) problems?
Yes No Do you have REMOVABLE dentures or partials? Upper Lower
Yes No Do you have a FEAR of Dentistry? If yes, why?
Yes No Do you like your SMILE?
Yes No Have you had a complete set of X-RAYS taken in the past 3 years? If yes, where?
Yes No Is your WATER FLUORIDATED?
Yes No Have you visited our web site at www.drmorin.com?
When was your last dental visit?
If you could change anything about your smile/teeth, what would that change be?
Tell us about your parents’ teeth.
Where do you rate your current level of dental health?

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poor
average
excellent
Where would you like it to be?

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poor
average
excellent
How do you want your teeth to look and feel in 20 years?

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Have dentures
Healthy teeth & beautiful smile

I hereby authorize HI-TECH Family Dentistry to administer dental treatment and local anesthetic and /or nitrous oxide (laughing gas) and to perform procedures deemed necessary in the diagnosis and dental treatment of the above named patient.

I further authorize HI-TECH Family Dentistry or anyone acting on his behalf to release information acquired in the course of the patient examination or treatment. I also consent to and authorize HI-TECH Family Dentistry to process insurance claims, communicate with insurers or other third parties, including my employer, who may have information pertaining to the payment of services.

I hereby assign to HI-TECH Family Dentistry benefits which are due or are to become due as a result of dental services rendered to the above mentioned patient. I hereby authorize that payments be made directly to HI-TECH Family Dentistry.

Dr. Morin often takes photos to better explain certain aspects of your existing dental health or planned treatment to you. We request your permission to show these photographs to better explain treatment options to other patients (as you will be shown photos for the same reason). And since he has a reputation as an expert on Cosmetic Dentistry, he also makes presentations to other dentists and professionals where the photos are invaluable in explaining the latest techniques and the results that can be achieved when done precisely. We also request your permission to post photographs of you and your smile on our website.

I agree to pay for all professional fees and treatment at the time of service, or my portion not covered by dental insurance, for myself or the above named patient, unless other financial arrangements are approved. I also agree to pay for all costs of collection, including attorney fees, and court costs, should additional means of collection be required.

* By typing my name and email address below and submitting this form, I hereby agree to these terms.

Name of Patient or Financially Responsible Party: Email: