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New Patients

Welcome to our dental practice! We are dedicated to providing the highest quality of dental care to our patients in a warm and welcoming environment. Our experienced team of dental professionals is committed to helping you achieve and maintain optimal oral health. Whether you are in need of routine preventive care or more complex dental treatments, we are here to provide you with the personalized care and attention you deserve. We look forward to meeting you and helping you achieve your best smile!

New Patient Paperwork

   Please Fill Out The Following:

  1. New Patient Form

  2. Additional Insurance Form (If needed)

  3. Dental History Form

  4. Medical History Form Part 1

  5. Medical History Form Part 2

  6. Authorization Form

New Patient Form

Patient Information

Marital Status

Primary Insurance

Additional Insurance

Is Patient Covered by Additional Insurance? If Not, Ignore This Section.

Thanks for registering with Callery Dental Care.

New Patient Form

Dental and Medical History

Please Fill Out The Fields Below, Then Submit.

Detal History Form
Dental History Form

Please select yes or no if you have had problems with any of the following

Bad Breath
Clicking or popping Jaw
Grinding or clenching teeth
Sensitivity to hot
Sensitivity to sweets
Do you wish your teeth were straighter?
Are you unhappy with any fillings, crowns, or bridges?
Bleeding gums
Food collection between teeth
Loose teeth or broken fillings
Sensitivity to cold
Sensitivity when biting
Do you wish your teeth were whiter?
Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?
Medical History Form Part 1
Are you currently under physician care?
Have you ever had a blood transfusion?
Have you ever taken Fen-Phen/ Redux?
Have you ever used a bisphosphonate medication? Brand names incude:Fosamax, Actonel, Atelvia, Didronal, and Boniva.
Do you smoke or use other tobacco/ smokeless products?
Please circle all that apply.
Women: Are you pregnant?
Women: Are you nursing?
Women: Are you taking birth conrol?
Arthritis, Rheumatism
Artificial joints
Atopic ( allergy prone )
Blood disease
Chemical dependency
Circulatory problems
Cough, persistent
Heart murmur
Hemophilian/ Abnormal bleeding
Jaw pain
AIDS/ HIV Positive?
Artificial heart valves
Back problems
Cortisone treatment
Cough up blood
Food allergies
Heart problems, if Yes, Please describe at bottom of form.
High blood pressure
Kidney diease or malfunction
Liver disease
Medical History Form
Medical History Form Part 2
Material allergies ( latex, wool, metal, chemicals )
Mitral valve prolapse
Nervous problems
Pacemaker/ Heart surgery
Psychiatric care
Radiation treatment
Rheumatic/ scarlet fever
Shortness of breath
Spina Difida
Surgical implant
Thyroid disease or malfunction
Ulcer/ Colitis
Rapid weight gain or loss
Respiratory disease
Skin rash
Swelling of feet or ankles
Tobacco habit
Venereal disease

Thanks for submitting!

Medical History Form Part2

Patient Authorization

Authorization Form
Authorization Form

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.
1 authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered.
I authorize the use of this signature on all insurance submissions.
1 authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Thanks for submitting!

Additional Insurance
Is patient covered by additional insurance?

Thanks for submitting!

Additional Insurance
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