New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.


[honeypot country]

About you

Title :
*Name :
 *Last name

 Mid name

 *First name
I prefer to be called : Sex : MaleFemale
*Your birthday : Age:
*Home address :
CityState
ZipAPT#
*Email address :Social security# :
Marital Status :
*Telephone Home : Cell phone# :
Telephone Work: Driver’s license# :
Employer :
Employer address :
CityState
ZipAPT#
How long there ? Occupation :
Where & when are best times to reach you?
How did you hear about us?
Have you visited our website? YesNo
Whom may we Thank for referring you?
Other family members seen by us :
Previous dentist :
Present dentist :
Person responsible for account :
Spouse information
His / Her name :
Employer :
Birthday : Social security# :
Telephone Work :
Driver’s license# :
Relative or friend not living with you
His / Her Name :
Relationship :
Telephone Work : Telephone Home :

Insurance information

Primary insurance
Dental coverage?YesNo
Insurance Co. name:
Address :
Street
CityState
Zip
Phone :
Group# (Plan, Local or Policy#):
Insured’s name :
Relationship :
Birthday :
SSN :
Insured’s employer :
Address :
Street
CityState
Zip
Secondary insurance
Dental coverage?YesNo
Insurance Co. name:
Address:
Street
CityState
Zip
Phone:
Group# (Plan, Local or Policy#):
Insured’s name:
Relationship:
Birthday:
SSN :
Insured’s employer:
Address:
Street
CityState
Zip

Medical History

Do you have a personal physician? YesNo
Physician’s Name :
Telephone home :

Date of last visit :

Your current physical health is :GoodFairPoor
Are you currently under the care of a physician?YesNo

Do you smoke or use tobacco in any other form?YesNo
Have you had any metal rods, pins or implants?YesNo
Are you taking any prescription / Over-the-counter drugs?YesNo

Have you ever taken Fosamax, or any other bisphosphonate?YesNo
Do you wear a cardiac pacemaker, or have you had heart surgery? YesNo

If so, when?

Are you required to take any medication before your dental visit? YesNo

If so, what?
For women :
Are you using a prescribed method of birth control? YesNo
Are you pregnant? YesNo Week # :
Are you nursing? YesNo
Have you ever had any of the following diseases or medical problems
YesNoAbnormal Bleeding / Hemophilia
YesNoAIDS related complex
YesNoAlcohol / Drug abuse
YesNoAnemia
YesNoArthritis
YesNoArtificial bones / Joints / Valves
YesNoAsthma
YesNoBlood transfusion
YesNoChemotherapy (Center, leukemia)
YesNoColitis
YesNoCongenital heart defect
YesNoDiabetes
YesNoDifficulty breathing
YesNoEmphysema
YesNoEpilepsy / seizures
YesNoExcessive bleeding
YesNoRespiratory disease
YesNoArtifical prosthesis
YesNoCongenital heart disease
YesNoX-Ray or cobalt treatment
YesNoFainting spells / seizures
YesNoFrequent headaches
YesNoGlaucoma
YesNoHay fever
YesNoHeart attack / Surgery
YesNoHeart murmur
YesNoHepatitis / jaundice
YesNoHerpes / Fever blisters
YesNoHigh blood pressure
YesNoAllergies or Hives
YesNoHospitalized for any reason
YesNoKidney disease
YesNoLiver disease
YesNoLow blood pressure
YesNoLupus
YesNoAngina pectoris
YesNoCerebral palsy
YesNoJoint replacement
YesNoNervous disorder
YesNoTumors or growths
YesNoMitral valve prolapse
YesNoPacemaker
YesNoPsychiatric treatment
YesNoRadiation treatment
YesNoRheumatic / Scarlet fever
YesNoShingles
YesNoSickle cell disease / Traits
YesNoSinus problems
YesNoStroke
YesNoThyroid problems
YesNoTuberculosis (TB)
YesNoUlcers
YesNoVenereal disease
YesNoTonsillitis
YesNoHead injuries
YesNoHeart failure
YesNoChicken pox
YesNoSinus Trouble
YesNoBlood disease
YesNoDrug addiction
Please list any serious medical condition(s) that you have ever had :
Are you allergic to any of the following?
YesNoAspirin
YesNoPenicillin
YesNoJewelry / Metals
YesNoAnesthetic (Novocain, ETC)
YesNoDental anesthetics
YesNoOther
YesNoErythromycin
YesNoSulfa Drugs
YesNoCodeine
YesNoTetracycline
YesNoLatex
Please list any other drugs / Materials that you are allergic to :

Dental History

Why have you come to the dentist today?
Are you currently in pain? YesNo
Do you require antibiotics before dental treatment? YesNo
Your current dental health is : GoodFairPoor
Have you ever had a serious/difficult problem associated with any previous dental work? YesNo
Do you floss daily? YesNo
Brush daily? YesNo
Type of bristles on your toothbrush? HardMediumSoft
Have you ever had gum treatment? YesNo
Do your gums ever bleed? YesNo
Ever Itch? YesNo
Have you ever had periodontal disease? YesNo
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? YesNo
Are your teeth sensitive to Heat or Cold? HeatCold
anything else?
Do you have any loose teeth? YesNo
Do you still have wisdom teeth? YesNo
Would you like fresher breath? YesNo
Whiter teeth? YesNo
Are you happy with the way your smile looks? YesNo
If not, what would you change?
I agree * The information and health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.
*Signature : Date :
Verification:
captcha