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Derby City Dental

For Patients Dentist Referrals
502-576-5345
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2902 Taylorsville Rd.
Louisville, KY 40205
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New Patient Form

New Patient Form

PATIENT INFORMATION

How did you hear about us?

RESPONSIBLE PARTY INFORMATION

Who is responsible for this account?

INSURANCE INFORMATION

Please take a moment to inform us of your medical history and your dental history so we may care for you more effectively and in such a way that accommodates your overall health and well-being.

Do you have dental benefits?

DENTAL HISTORY

Please take a moment to inform us of your medical and dental history so that we may care for you more effectively and in such a way that accommodates your overall health and well-being.

Are you in discomfort?
Are any of your teeth sensitive?
Do your gums bleed or hurt?
Are you satisfied with your teeth's appearance?

MEDICAL HISTORY

Are you currently seeing any medical specialists?
Do you smoke or use smokeless tobacco (including e-cigarettes)?)
Have you had a joint or heart valve replacement?
Have you been prescribed antibiotic premedication? (if yes, please take as prescribed prior to your exam)
Do you use a CPAP?
Do you have any drug allergies?
Have you had cancer?
Heart attack/stroke:
Autoimmune disease:
Heart surgery:
Pacemaker/defibrillator:
Do you take or have you taken bisphosphonates?
Do you take blood thinners?
Are you pregnant?
Have you taken any medication in the last 12 months?

Contact Us

At Derby City Dental Specialists, we offer innovative treatments for gum disease including dental implants. If you want to know more about dental implants or any other procedure, schedule an appointment with Derby City Dental Specialists.

Contact Us

Hours of Operation

Monday8:00 am - 5:00 pm
Tuesday8:00 am - 5:00 pm
Wednesday8:00 am - 5:00 pm
Thursday8:00 am - 4:00 pm
Friday8:00 am - 12:00 pm
SaturdayCLOSED
SundayCLOSED
2902 Taylorsville Rd.
Louisville, KY 40205 502-576-5345