Patient Forms

Dental Patient Forms

For your convenience, Woodyard Dental Care has the following new patient forms to print, fill in on your own time, then bring to your first appointment:

Patient Forms

Patient Information Form

Patient information

Marital Status
Is it acceptable to contact you by text and /or email?
Place of employment
Spouse/Parent Place of Employment
Other family members seen in our office
Referred By:

Dental Insurance

Patient's Relationship to Subscriber
Name of Dental Insurance Company

Patient Health History Information

Prior Dentist / Dentaline Clinic Name
City / State
Last Dental Exam
Last Dental X-Ray
Physician / Medical Clinic Name
Last Physical Exam
Do you smoke or use tobacco products?

Allergies - Select all that apply

Other Allergy

Medical Conditions - Please select all that apply

Other Condition

Medications - Please list any medications you are currently taking