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 do you have that you would like Dr. O’Rielly’s help to resolve?*
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?*
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?*
Please list all dentists and/or specialists you have seen over the last year, and the treatment that has been recommended to you.
Has the treatment been done? Has there been any difficulties or complications with past treatment? This will help us to understand your unique needs and your situation.
Are you currently in treatment for any health challenges and do you have any dental anxiety or special needs that could affect dental treatment?

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