New Patient Forms

To save time fill out the form below or click here to print our new patient forms.

This confidential information will help us prepare for your visit

Prefix:
First name:
Last name:
Preferred name:
Birthdate:
Social Security Number:
Address:
Address 2:
City:
State:
Zip:
Marital status:
Cell phone:
Work phone:
Home phone:
Email address:
Employer:
Employer address:
Occupation:
Years at job:
Best time to call:
Preferred method of contact:
Who referred you:
Other family members seen by us:
Spouse name:
Spouse birthdate:
Spouse employer:
Spouse employer address:
Spouse occupation:
Spouse years at job:
Name on account:
Payment plan preferred:	Please select one
Why have you made this dental appointment?
Why did you leave the office of your previous dentist?
My mouth is:
Smile appearance:
Recommendations:
Dental care priority:
Current dental health:
Obstacles to having excellent dental care:	I see no obstacles Time away from work or other obligations Fear of pain, surgery, or injections Fear because of past dental experiences The cost of treatment Other
Current medical health:
Are you under the care of a physician?
Physician name:
Physician office location:
Physician office telephone:
List all medications you take (prescription and over counter):
Conditions:	Heart Attack Heart Murmur Scarlet Fever Cancer HIV / AIDS Fever Blisters Stroke Diabetes Ulcers Anemia Arthritis Fainting Have you ever taken Phen Phen Heart Surgery Pacemaker Hepatitis Chemotherapy Shingles Cold Sores Sinus Trouble Tuberculosis Colitis Asthma Emphysema Glaucoma Mitral Valve Prolapse Rheumatic Fever Kidney Problems Radiation Treatment Artificial Joint Artificial Valve Epilepsy / Seizures Psychiatric Problems Drug / Alcohol Dependence Hemophelia / Bleeding Venereal Disease Difficulty Breathing Hospitalized High / Low Blood Pressure Blood Transfusion Severe or Frequent Headaches None of the above apply to me
Allergies:	Penicillin Aspirin Sulfa Tetracycline Codeine Erythromycin Latex Dental Anesthetic Other
Do you excercise regularly?
If YES, what do you enjoy doing?
Are you taking birth control?
Are you pregnant?
Are you nursing?
How long does it take you to fall asleep?
How many times do you awaken each night?
How many hours do you sleep each night?
Do you awaken rested?
Insured name:
Insured birthdate:
Insured Social Security Number:
Insured employer:
Insurance company:
Group number:
Electronic signature:

Dr. Dianna Lenick Aesthetic & Family Dentistry 1311 Quarrier Street Charleston, WV 25301 Phone: 866-342-6918 (Toll Free)