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Sat – Sun 8 AM – 5PM
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A Dental Care Houston,TX
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All on 4 Dental Implants
All on 4 vs All on 6 Dental Implants
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Menu
Home
Our Offices
Greenspoint Office
Gulfgate Office
Tidwell Office
Union Dental Office
Spring Office
Procedures
Cosmetic Dentistry
Porcelain Dental Veneers & Lumineers
Smile Analysis
Teeth Whitening
Orthodontics
Braces For Adults
Braces For Children
Invisalign
Periodontics
Periodontal Maintenance
Periodontal Treatment
Preventive Dentistry
Dental Exams & Cleanings
Digital X-Rays
Oral Hygiene
Restorative Dentistry
Composite Dental Fillings
Dental Implants
Single Tooth Implant
Implant Supported Dentures
Implant Supported Bridges
All on 4 Dental Implants
All on 4 vs All on 6 Dental Implants
Dentures & Partials
Porcelain Dental Crown
Porcelain Fixed Dental Bridges
Root Canal Therapy
Wisdom Teeth Removal
Galleries
Dental Videos
Smile gallery
New Patients
Financial Option
Patient Forms
Greenspoint Patient Login
Special Offers
Testimonials
Job
Blog
Contact us
Call Us:
281-476-4537
Schedule Online
281-476-4537
Schedule Online
Home
Our Offices
Greenspoint Office
Gulfgate Office
Tidwell Office
Union Dental Office
Spring Office
Procedures
Cosmetic Dentistry
Porcelain Dental Veneers & Lumineers
Smile Analysis
Teeth Whitening
Orthodontics
Braces For Adults
Braces For Children
Invisalign
Periodontics
Periodontal Maintenance
Periodontal Treatment
Preventive Dentistry
Dental Exams & Cleanings
Digital X-Rays
Oral Hygiene
Restorative Dentistry
Composite Dental Fillings
Dental Implants
Single Tooth Implant
Implant Supported Dentures
Implant Supported Bridges
All on 4 Dental Implants
All on 4 vs All on 6 Dental Implants
Dentures & Partials
Porcelain Dental Crown
Porcelain Fixed Dental Bridges
Root Canal Therapy
Wisdom Teeth Removal
Galleries
Dental Videos
Smile gallery
New Patients
Financial Option
Patient Forms
Greenspoint Patient Login
Special Offers
Testimonials
Job
Blog
Contact us
Menu
Home
Our Offices
Greenspoint Office
Gulfgate Office
Tidwell Office
Union Dental Office
Spring Office
Procedures
Cosmetic Dentistry
Porcelain Dental Veneers & Lumineers
Smile Analysis
Teeth Whitening
Orthodontics
Braces For Adults
Braces For Children
Invisalign
Periodontics
Periodontal Maintenance
Periodontal Treatment
Preventive Dentistry
Dental Exams & Cleanings
Digital X-Rays
Oral Hygiene
Restorative Dentistry
Composite Dental Fillings
Dental Implants
Single Tooth Implant
Implant Supported Dentures
Implant Supported Bridges
All on 4 Dental Implants
All on 4 vs All on 6 Dental Implants
Dentures & Partials
Porcelain Dental Crown
Porcelain Fixed Dental Bridges
Root Canal Therapy
Wisdom Teeth Removal
Galleries
Dental Videos
Smile gallery
New Patients
Financial Option
Patient Forms
Greenspoint Patient Login
Special Offers
Testimonials
Job
Blog
Contact us
GulfGate New Patient form
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions we’ll be glad to help you. We look forward to working with you on maintaining your dental health.
Patient Information
First Name
(Required)
Middle Name
(Required)
Last Name
(Required)
Marital Status
(Required)
Married
Single
Child
Gender
(Required)
Male
Female
Birth Date
(Required)
MM slash DD slash YYYY
Phone(Cell)
(Required)
Phone(Work)
(Required)
Phone(Home)
(Required)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email Address
(Required)
Notify In Case of Emergency
Person Name
Phone Number for Emergency Contact
Whom May We Thank For Referring You
Please select one option
Google
Friends & Family
Insurance Website
Flyer
Walk-In
Other
Name of Person
(Required)
Other
(Required)
Please upload one of the followings: Valid ID, Valid Driver License, Passport, or any other proof of Identification.
Max. file size: 25 MB.
Primary Insurance
Primary Insurance
Yes
No
Front of Insurance Card
(Required)
Max. file size: 25 MB.
Back of Insurance Card
Max. file size: 25 MB.
Name of Insured
First
Last
Insured's Birth Date
(Required)
MM slash DD slash YYYY
SS#
Group#
Subscriber#
Insured's Employer Name
Insurance Company Phone Number
Patient's relationship to insured
Self
Spouse
Child
Other
Name of other Dependents under the Plan
(Required)
Secondary Insurance
Secondary Insurance
Yes
No
Front of Insurance Card
(Required)
Max. file size: 25 MB.
Back of Insurance Card
Max. file size: 25 MB.
Name of Insured
First
Last
Insured's Birth Date
(Required)
MM slash DD slash YYYY
SS#
Group#
Subscriber#
Insured's Employer Name
Insurance Company Phone Number
Patient's relationship to insured
Self
Spouse
Child
Other
Name of other Dependents under the Plan
(Required)
PHARMACY
Name
Phone Number
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Dental History
What would you like us to do today?
(Required)
Are you in dental discomfort today?
(Required)
Yes
No
Select Yes or No if you have had problems with any of the following
Bad Breath
(Required)
Yes
No
Food collection between teeth
Yes
No
Periodontal treatment
Yes
No
Sensitivity to sweets
Yes
No
Bleeding gums
Yes
No
Grinding or clenching teeth
Yes
No
Sensitivity to cold
Yes
No
Sensitivity when biting
Yes
No
Clicking or popping jaw
Yes
No
Loose teeth or broken filings
Yes
No
Sensitivity to hot
Yes
No
Sores or growths in mouth
Yes
No
How often do you brush?
(Required)
How often do you floss?
(Required)
How do you feel about the appearance of your teeth?
(Required)
Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?
(Required)
Yes
No
Other information about your dental health or previous treatment
Medical History
Physician's Name
Phone
Date of last visit
MM slash DD slash YYYY
Have you had any serious illness or operations?
(Required)
Yes
No
Are you currently under physician care?
(Required)
Yes
No
Have you ever had a blood transfusion?
(Required)
Yes
No
Have you ever had taken Fen-Phen/Redux?
(Required)
Yes
No
Select Yes or No if you have had problems with any of the following
AIDS/HIV Positive
(Required)
Yes
No
Anaphylaxis
(Required)
Yes
No
Anemia
(Required)
Yes
No
Artificial heart valves
(Required)
Yes
No
Asthma
(Required)
Yes
No
Artificial joints
(Required)
Yes
No
Asthma
(Required)
Yes
No
Atopic (allergy prone)
(Required)
Yes
No
Back problems
(Required)
Yes
No
Blood disease
(Required)
Yes
No
Cancer
(Required)
Yes
No
Chemical dependency
(Required)
Yes
No
Chemotherapy
(Required)
Yes
No
Circulatory problems
(Required)
Yes
No
Cortisone treatments
(Required)
Yes
No
Cough up blood
(Required)
Yes
No
Cough, persistent
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Epilepsy
(Required)
Yes
No
Fainting
(Required)
Yes
No
Food allergies
(Required)
Yes
No
Glaucoma
(Required)
Yes
No
Headaches
(Required)
Yes
No
Heart murmur
(Required)
Yes
No
Heart problems
(Required)
Yes
No
Hemophilia/Abnormal bleeding
(Required)
Yes
No
Hepatitis
(Required)
Yes
No
Herpes
(Required)
Yes
No
High blood pressure
(Required)
Yes
No
Jaw pain
(Required)
Yes
No
Kidney disease or malfunction
(Required)
Yes
No
Liver disease
(Required)
Yes
No
Latex Allergy
(Required)
Yes
No
Material allergies(latex, wool, metal, chemicals)
(Required)
Yes
No
Mitral valve prolapse
(Required)
Yes
No
Nervous problems
(Required)
Yes
No
Pacemaker/Heart surgery
(Required)
Yes
No
Psychiatric care
(Required)
Yes
No
Radiation treatment
(Required)
Yes
No
Rapid weight gain or loss
(Required)
Yes
No
Respiratory disease
(Required)
Yes
No
Rheumatic/Scarlet fever
(Required)
Yes
No
Shingles
(Required)
Yes
No
Shortness of breath
(Required)
Yes
No
Skin rash
(Required)
Yes
No
Spina Bifida
(Required)
Yes
No
Stroke
(Required)
Yes
No
Surgical implant
(Required)
Yes
No
Swelling of feet or ankles
(Required)
Yes
No
Thyroid disease or malfunction
(Required)
Yes
No
Tobacco habit
(Required)
Yes
No
Tonsillitis
(Required)
Yes
No
Tuberculosis
(Required)
Yes
No
Ulcer/Colitis
(Required)
Yes
No
Venereal disease
(Required)
Yes
No
Other health conditions
Do you have to take antibiotic premedication for your dental visit?
(Required)
Yes
No
Please list all medications Patients take: (Write NA if not applicable)
Medication 1
Name of Medication
Dose
Reason
Medication 2
Name of Medication
Dose
Reason
Medication 3
Name of Medication
Dose
Reason
Additional Medications (other than above)
Name of Medication
Dose
Reason
Does patient have drug allergies
(Required)
Yes
No
List all drug allergies
x
x
x
x
x
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