(334)-819-7377 smile@pikeroaddental.com

Patient Forms

Dental Services for the whole family

New Patient Form

We love putting our patients first at Pike Road Dental. We want your visit to be as enjoyable of an experience as possible. Therefore, if you would like to reduce the number of forms you have to fill out when you arrive, please complete the form below. Our website is HIPPA compliant, and meets the necessary security standards in order to collect such information. However, if you feel more comfortable printing this form out, completing it, and then bringing it to your appointment, click the link below.

 Download New Patient Form

New Patient Form

General Information

Sex *
Marital Status *

Primary Insurance

Secondary Insurance

Party responsible for payment (if not self):

Medical History / Information

General Health Condition: *
Are you currently on medication? *
Have you ever taken bone medication? *
Have you ever been treated for any of the following conditions?
Mitral valve prolapse *
Heart disease *
Rheumatic fever *
Heart murmur *
High blood pressure *
Low blood pressure *
Congenital heart lesions *
Jaundice
Venereal disease *
HIV / AIDS *
Ulcers *
Lung Disease *
Diabetes *
Epilepsy *
Hay fever *
Sinus Trouble *
Hepatitis *
Arthritis *
Stroke *
Glaucoma *
Joint Replacement *
Cancer *
HPV *
Tuberculosis *
Asthma *
Bone Density *
Other Treatment *
Do you smoke? *
Are you allergic to any of the following items?
Penicillin *
Codeine *
Local injected anesthetics *
Latex *
Other *
Do you have prolonged bleeding? *
Are you pregnant? *

Get in Touch

334-819-7377
smile@pikeroaddental.com

Come On In

31 Bridge St
Pike Road, Alabama

Contact us for Appointments!