Elliot Jolley, DMD


582 North 1700 West
Vernal, UT, 84078
(435) 781-1234
481 West 200 North
Roosevelt, UT 84066
(435) 722-1233

New Patient Form

Patient Information


Patient's First and Last Name

Prefered Name

Date of Birth


Social Security Number

Mailing Address




Zip Code

Contact Information

Prefered Phone Number

Alternate Phone Number

Email Address

Other Information

Are You A Student?

If so, what school to you attend?

Who is you Dentist?

Date of Last Dental Vist

Who is you Physician?

Date of Last Physician Vist

Were your reffered to us?

If so, by whom?

Billing Party


First and Last Name

Relation to Patient

Date of Birth

Marital Status

Spouse (If Applicable)

Employer (If Applicable)

Social Security Number

Billing Address




Zip Code

Contact Information

Prefered Phone Number

Alternate Phone Number

Email Address

Insurance Information

As a courtesy to our patients, we will be happy to file insurance claims on your behalf. We can provide pre-authorizations if needed and are working to help you maximize your insurance benefits. To have claims processed in a timely manner we do need a copy of your dental insurance card, and the following infomation filled out completely.

Do you have dental insurance?

Insurance Company

Policy ID Number

Group Number

Effective Date

Is it an Employer Plan?

If an Employer Plan...

Employer Name

Employer Address



Zip Code

Employer Phone Number

Medical Information

Medical Issues

Check the box if you have, or if you ever had, any of the following

☐ Birth Defects of Hereditary Problems

☐ Bone Fractures, any Major Accidents

☐ Rheumatoid or Arthritic Conditions

☐ Endocrine or Thyroid Problems

☐ Kidney Problems

☐ Diabetes

☐ Cancer, Tumor, Radiation treatment, or Chemotherapy

☐ Stomach Ulcer or Hyperacitity

☐ Polio, Mononucleosis, Tuberculosis, or Pnemonia

☐ Problems of the Immune System

☐ AIDS or HIV Positive

☐ Hepatitis, Jaundice, or Liver Problems

☐ Fainting Spells, Seizures, Epilepsey, or Neurological Problems

☐ Mental Health Disturbance or Depression

☐ Vision, Hearing, Tasting, or Speech Difficulties

☐ Rapid Weight Loss, Poor Appetite

☐ Eating Disorders (Anorexia, Bullima)

☐ Excessive Bleeding or Bruising Tendency, Anemia, or Bleeding Disorder

☐ High or Low Blood Pressure

☐ Tired Easilly

☐ Chest Pain, Shortness of Breath, or Swelling Ankles

☐ Cardiovascular Problems (Hear Trouble, Heart Attack, Angina, Coronary Insufficiency, Arterosclerosis, Stroke, Inborn Heart Defects, Heart Murmer, or Rheumatic Heart Disease)

☐ Skin Disorder

☐ Freaquent Headaches, Colds, or Sore Throats

☐ Eye, Ear, Nose, or Throat Condition

☐ Hayfever, Asthma, Sinus Trouble, or Hives

☐ Tonsil or Adenoid Conditions

☐ Osteoporosis

☐ Substance Abuse Problems

☐ Chewed or Smoked Tobacco

Women Only

☐ Are You Prenant?

☐ Are You Currently Taking Birth Control?


☐ Metals (Jewlery, Clothing Snaps)

☐ Latex (Gloves, Balloons)

☐ Vinal

☐ Acrylic

☐ Other (Please Specify)

Medication and Supplements

Please List any Medication, Dietary Supplements, Herbal Medications, or Non-Perscription Medicine You are Currently Taking

Dental Information

Dental Issues

Check the box if you have, or if you ever had, any of the following

☐ Permanent or "Extra" (Supernumerary) Teeth Removed

☐ Teeth Sensitive to Hot or Cold; Teeth Throb or Ache

☐ "Dead Teeth" or Root Canals Treated

☐ Peridontal "Gum Problems"

☐ "Gum Boils", Frequent Canker Sores or Cold Sores

☐ Abnormal Swallowing Habbit (Tongue Thrusting)

☐ Mouth Breating Habbit, Snoring, or Difficulty Breathing

☐ Any Pain, Clicking, or Locking of the Jaw or Ringing in the Ears

☐ Local Anesthetics (Novocain or Lidocaine)

☐ Aware of any Loose, Broken, or Missing Restorations (Filling)

☐ Any Relatives with Similar Tooth or Jaw Relationships

☐ Had Peridontal (Gum) Treatment

☐ Concerned about Spaced, Protruding, or Crooked Teeth

☐ Supernumerary (Extra) or Congenitally Missing Teeth

☐ Jaw Fractures, Cysts, or Mouth Infections

☐ Bleeding Gums, Bad Taste, or Mouth Odor

☐ Food Impactions Between Teeth

☐ History of Speech Problems

☐ Tooth grinding or Jaw Clenching

☐ Difficulaty Chewing or Opening Jaw

☐ Been treated for TMD or TMJ

☐ Any Teeth Irritating Cheek, Lip, Tongue, or Palate

☐ Wisdom Teeth Problems

☐ Had any Serious Touble Associated with any Previous Dental Treatment

☐ Aware or Concerned About Under or Over Developed Jaw

☐ Prior Orthodontic Examination or Treatment

☐ Thumb, Finger, or Sucking Habbit Until Age

Other Dental Information

Have you ever been under another dentist's or dental specialist's care? If so, who? Also, what was their field of specialty if applicable.

How Often do you Brush?

How Often do you Floss?


What are your primary Concerns? Why are you here?

Anything else we should know?

I have read and understand the above questions. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history, record or medical/dental status, I will so inform this practice.