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New Patient Form

Thank you!

We can't wait to meet with you. If you could please answer the following information on a desktop computer so we can help you get your best sleep! 

Contact Info
Sleep Questionnaire

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 = would never doze

1= slight chance of dozing

2 = moderate change of dozing

3 = high chance of dozing

It is important that you answer each question as best you can.


Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g. a theater or a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in traffic

Chance of Dozing (0-3)

Sleep Info

Usual bedtime (lights out)

Normal wake time (lights on)

Average number of times waking up at night

Feel refreshed when waking up?

Have you or your bed partner noticed snoring?

Have you or your bed partner noticed gasping for air?


Dental Info

Have you ever been diagnosed with periodontal (gum) disease?

Do you have any loose teeth?

Do you have any tooth pain?

Have you ever been diagnosed with TMD/TMJ?

Has your jaw ever been locked in the open position or had pain in the jaw joint?

Do you clench or grind your teeth?

Are you currently under the regular care of a dentist?

Please upload dental x-rays if taken within the past year:

Upload File
Medical History

Please write which of the illnesses you had or currently have in the entry box below:


Allergy - Latex

Allergy - Anesthetics

Allergy - Other

Alzheimer's Disease




Artificial Joints (specify)



Blood Disease (specify)

Taking Blood Thinner






Excessive Bleeding



Heart Disease

Heart Murmur

Hepatitis A

Hepatitis B

Hepatitis C

High Blood Pressure

High Cholesterol

Kidney Disease

Knee Replacement

Liver Disease


Mitral Valve Prolapse


Requiring Premed

Radiation Treatment

Respiratory Problems

Rheumatic Fever


Sinus Problems


Thyroid Problems



Ulcers/Stomach Problems

Social History:

Medical Insurance

Please upload pictures or scan of your medical insurance card.

Primary Insurance (front of card):

Upload Picture

Primary Insurance (back of card):

Upload Picture

Secondary Insurance (front of card):

Upload Picture

Secondary Insurance (back of card):

Upload Picture
Consent for Services and Financial Policy

GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Spira Dental to take radiographs, study models, photographs, or any other diagnostic tools deemed appropriate to make a thorough diagnosis of the undersigned patient's dental condition and needs. I authorize Spira Dental to perform any and all forms of treatment, medication, and therapy that may be deemed necessary by the doctors. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my / the patient's health. It is my responsibility to inform the dental office of any change in medical health or status.

FINANCIAL CONSENT: I understand the responsibility for payment of services provided for myself and my dependent(s) is mine. As a courtesy we will be happy to assist in filing insurance. The office will collect your estimated portion on the day service is rendered and wait 30 days to obtain the balance from my insurance. I understand that I am responsible for any portion of fees not covered by my medical insurance after 30 days. Spira Dental and staff will provide care based on the patient's needs and not based on insurance coverage. I authorize Spira Dental and their staff to verify insurance coverage, submit claims, and provide my insurance company with information required for processing claims. I also give permission to assign benefits directly to Spira Dental and for this company to handle any necessary claim appeals on my behalf.

HIPAA Acknowledgement

I understand that I may inspect or copy the protected health information described by this authorization. I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

I authorize this company to release any financial or medical/dental information to the following person(s) listed below:


Name of patient, parent, or guardian completing this form:

Relationship to patient:

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