(770) 475-7551
3005 Old Alabama Road, Suite 320 Alpharetta, GA 30022

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We love hearing from our patients! Read what our patients have said about us!

New Patient Forms

Patient Full Name*
Preferred Name
Date*
Marital Status
- Single
- Married
- Separated
- Divorced
- Widowed
Address*
Home Address City State ZIP Code
Telephone (Home)*
(Office)
(Cell)*
SSN
Email*
How Did You Hear About Us? If Referred, by Whom?
Is Another Member of Your Family or a Relative in Our Practice
- Yes
- No
Name
Relationship
Emergency
Who Would You Like Us to Contact FIRST in Case of an Emergency?*
Relationship to Patient
Address
Home Address City State ZIP Code
Telephone (Home)
(Office)
(Cell)
Financial
Who is Financially Responsible for the Payment of Your Account?*
Relationship to Patient
Phone Number, if Different fromPatient
Address
Home Address City State ZIP Code
PAYMENT IN FULL IS DUE AT THE TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED. We will submit your insurance claim for you. However, we do not accept assignment.
Insurance Information
Insurance Co. Name
Group #
Insurance Co. Customer Service Phone
Insurance Co. Address
Home Address City State ZIP Code
Subscriber's Name
Relation
Subscriber's Date of Birth
Subscriber's SSN
Subscriber's Employer
The information that I have given is true and correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence. I hereby authorize the doctor or designated staff to take x-rays, study models, bacteriological cultures, diagnostic casts, photographs, biopsies of oral tissue, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the above name patient’s dental needs. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I consent to the use of appropriate medication and therapy as deemed necessary. I fully understand that using anesthetic agents embodies a certain risk. I understand that I am responsible for the total fee for the services rendered.
Patient/Parent/Guardian Signature*
Date*
PATIENT HEALTH HISTORY
Recent research indicates a strong relationship between the mouth and body. We are going to be asking you some questions about your family history and your overall health that we may not have asked you about before.
Name*
Telephone (Home)*
(Office)
(Cell)*
Email*
Are You Under the Care of Physician?
- Yes
- No
Primary Care Physician
Have You Had Any Serious Illnesses or Operations in the Last 5 Years?
- Yes
- No
Describe
Have You Ever Had a Blood Transfusion?
- Yes
- No
If yes, When?
Are You on a Blood Thinner?
- Yes
- No
Are You Pregnant?
- Yes
- No
Are You Nursing?
- Yes
- No
Are You Taking birth controls pills?
- Yes
- No
Check if You Currently Have or Have a History of the Following:
- Artificial Hip or Knee Joint
- Heart Murmur
- Rheumatic Fever
- Diabetes
- Hepatitis
- Alcohol Abuse
- Congenital Heart Disease
- Kidney Disease/Stones
- Drug Abuse
- COPD
- Mitral Valve Prolapse
- Anemia
- Nervous/Anxious
- Pacemaker
- Arthritis
- Epilepsy/Seizures
- Sinus
- Artificial Heart Valve
- Glaucoma
- Stroke
- Asthma
- Heart Attack/Cardiac Issues
- Thyroid
- Bruise Easily
- HIGH/LOW blood pressure
- Tuberculosis
- Cancer
- HIV/AIDS
- Ulcers
- Chemotherapy/Radiation
- Hypoglycemia
- Venereal Disease
Artificial Hip or Knee Joint, If Yes, Premed?
- Yes
- No
Heart Murmur, If Yes, Premed?
- Yes
- No
Rheumatic Fever, If Yes, Premed?
- Yes
- No
- Other
Check if You Are Allergic To or Have Reacted Adversely to Any of the Following:
- Aspirin
- Codeine/Other Narcotics
- Latex
- Barbiturates (Sleeping Pills)
- Iodine
- Local Anesthetics
Antibiotics:
- Penicillin
- Erythromycin
- Sulfa
- Tetracycline
- Other
Check if You are Having Problems with Any of the Following:
- Bleeding Gums
- Grinding Teeth
- Sensitivity to Hot or Cold
- Clicking or Popping Jaw
- Sensitivity When Chewing
- Dry Mouth
- Mouth Breathing
- Sores or Growths in Your Mouth
Gum disease has been linked with an increased risk for many chronic diseases. Eliminating gum disease is especially important to the oral and overall health.
Tobacco User
Tobacco users are more likely to develop gum disease which is more severe and more difficult to eradicate. Gum disease itself has recently been linked with an increased risk for heart disease. Since tobacco users are already at an increased risk for heart disease, and gum disease only worsens the risk, it is vitally important for tobacco users to do whatever is necessary to eliminate gum disease.
Current Tobacco User?
- Yes
- No
What Form (Cig, Pipe, Chew, etc.)
Previous Tobacco User?
- Yes
- No
When Did You Quit?
Diabetes
Diabetes is well –known risk factor for gum disease. Research is confirming that when left untreated gum disease makes it harder for you to control your blood sugar. Elimination of gum disease can improve your blood sugar control reducing your risk for the serious complications.
How is your diabetes control?
- Good
- Fair
- Poor
Family History of Gum Disease
Some people are genetically prone to developing gum disease even if they take excellent care of their mouths.
Do you have any family history of gum disease?
- Yes
- No
- Don't Know
Stress
Stress is a well-known risk factor for gum disease. Is your stress level too high?
- Yes
- No
Rheumatoid Arthritis
There is a bi-directional connection between rheumatoid arthritis. If you have arthritis you are at an increased risk for gum disease. Emerging research suggests that eliminating any gum disease and then keeping it at bay can lessen the crippling effects of arthritis.
Medication
Purpose
Dose
How Long?
Other Comments
The information that I have given is true and correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence. I hereby authorize the doctor or designated staff to take x-rays, study models, bacteriological cultures, diagnostic casts, photographs, biopsies of oral tissue, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the above name patient’s dental needs. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I consent to the use of appropriate medication and therapy as deemed necessary. I fully understand that using anesthetic agents embodies a certain risk. I understand that I am responsible for the total fee for the services rendered.
Patient/Parent/Guardian Signature*
Date*

Location
3005 Old Alabama Road
Suite 320
Alpharetta, GA 30022
Email us at frontoffice@sabledds.com
Fax: (770) 475-7540

Hours
Monday: 8:00 a.m. – 5:00 p.m.
Tuesday: 7:00 a.m. – 4:00 p.m.
Wednesday 8:00 a.m. – 5:30 p.m.
Thursday 7:00 a.m. – 4:00 p.m.

By Appointment

Find Us

Home
About
- Meet the Team
- Office Gallery
Services
COVID-19 Office Update
- Patient Protocols Under COVID-19
Reviews
New Patient
- New Patient Forms
- Financial
Special Announcements
Smile Gallery
Contact
- Pay Online

New Patient Forms

Emergency

Financial

Insurance Information

PATIENT HEALTH HISTORY

Recent research indicates a strong relationship between the mouth and body. We are going to be asking you some questions about your family history and your overall health that we may not have asked you about before.