New Patient Registration

Posted: January 29, 2014 — No Comments ↓

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

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About you

Title :

*Name :

*Last name

Mid name

*First name

I prefer to be called :

Sex : MaleFemale

*Your birthday :

Age:

*Home address :


City		State
Zip		APT#

*Email address :

Social security# :

Marital Status :

*Telephone Home :

Cell phone# :

Telephone Work:

Driver’s license# :

Employer :

Employer address :


City		State
Zip		APT#

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
City		State
Zip

Phone :

Group# (Plan, Local or Policy#):

Insured’s name :

Relationship :

Birthday :

SSN :

Insured’s employer :

Address :

Street
City		State
Zip

Secondary insurance

Dental coverage?

YesNo

Insurance Co. name:

Address:

Street
City		State
Zip

Phone:

Group# (Plan, Local or Policy#):

Insured’s name:

Relationship:

Birthday:

SSN :

Insured’s employer:

Address:

Street
City		State
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

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

YesNo

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

YesNo	Abnormal Bleeding / Hemophilia
YesNo	AIDS related complex
YesNo	Alcohol / Drug abuse
YesNo	Anemia
YesNo	Arthritis
YesNo	Artificial bones / Joints / Valves
YesNo	Asthma
YesNo	Blood transfusion
YesNo	Chemotherapy (Center, leukemia)
YesNo	Colitis
YesNo	Congenital heart defect
YesNo	Diabetes
YesNo	Difficulty breathing
YesNo	Emphysema
YesNo	Epilepsy / seizures
YesNo	Excessive bleeding
YesNo	Respiratory disease
YesNo	Artifical prosthesis
YesNo	Congenital heart disease
YesNo	X-Ray or cobalt treatment
YesNo	Fainting spells / seizures
YesNo	Frequent headaches
YesNo	Glaucoma
YesNo	Hay fever
YesNo	Heart attack / Surgery
YesNo	Heart murmur
YesNo	Hepatitis / jaundice
YesNo	Herpes / Fever blisters
YesNo	High blood pressure
YesNo	Allergies or Hives

YesNo	Hospitalized for any reason
YesNo	Kidney disease
YesNo	Liver disease
YesNo	Low blood pressure
YesNo	Lupus
YesNo	Angina pectoris
YesNo	Cerebral palsy
YesNo	Joint replacement
YesNo	Nervous disorder
YesNo	Tumors or growths
YesNo	Mitral valve prolapse
YesNo	Pacemaker
YesNo	Psychiatric treatment
YesNo	Radiation treatment
YesNo	Rheumatic / Scarlet fever
YesNo	Shingles
YesNo	Sickle cell disease / Traits
YesNo	Sinus problems
YesNo	Stroke
YesNo	Thyroid problems
YesNo	Tuberculosis (TB)
YesNo	Ulcers
YesNo	Venereal disease
YesNo	Tonsillitis
YesNo	Head injuries
YesNo	Heart failure
YesNo	Chicken pox
YesNo	Sinus Trouble
YesNo	Blood disease
YesNo	Drug addiction

Please list any serious medical condition(s) that you have ever had :

Are you allergic to any of the following?

YesNo	Aspirin
YesNo	Penicillin
YesNo	Jewelry / Metals
YesNo	Anesthetic (Novocain, ETC)

YesNo	Dental anesthetics
YesNo	Other
YesNo	Erythromycin
YesNo	Sulfa Drugs

YesNo	Codeine
YesNo	Tetracycline
YesNo	Latex

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:

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