New Patient History Form

Please be sure to click the Submit button once completed.

More information for new patients can be found here.

Full Name*
Email*
Phone*
Where are you located?*
How did you hear about Dr. O'Rielly?*
Are you currently in pain?*
Describe the pain: its location, its strength from 1-10 and how long you have had it.
What dental issues would like Dr. O’Rielly’s help to resolve?*
Are you looking for Dr. O'Rielly to become your primary dentist?*
When was your last set of Xrays taken?*
Please e-mail current Xrays to [email protected]
We request current Xrays so Dr. O can evaluate how best to set up your first appointment. If current ones are unavailable, we will take new ones. Please send all relevant imaging.
Date Format: MM slash DD slash YYYY
When was your last cleaning and how often do you have your teeth cleaned?*
Have you ever been told you have gum disease?*
Have you had any root canals in the past? If so, are you having any issues with them?*
Have there been any difficulties or complications with past dental treatment? Do you have any dental anxiety or special needs that could affect dental treatment?
This will help us to understand your unique needs and your situation.
Are you currently in treatment for any health challenges?

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