Charlotte Dentist » New Patient RegistrationNew Patient Registration Please note that it is important to fill in all the fields before submitting. Thank you. Please leave this field empty.About youTitle :MrMrsMsDr*Name : *Last name Mid name *First nameI prefer to be called : Sex : MaleFemale*Your birthday : Age: *Home address :CityState ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipAPT#*Email address :Social security# : Marital Status :SingleMarriedPartneredDivorced/SeparatedWidowed*Telephone Home : Cell phone# : Telephone Work: Driver’s license# :Employer :Employer address :CityState ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipAPT#How long there ? Occupation : Where & when are best times to reach you? How did you hear about us? ---InternetFacebookYellow PagesNewspaperPostcard / FlyerReferral Have you visited our website? YesNoWhom may we Thank for referring you? Other family members seen by us : Previous dentist :Present dentist :Person responsible for account : Spouse informationHis / Her name :Employer :Birthday : Social security# : Telephone Work : Driver’s license# :Relative or friend not living with youHis / Her Name :Relationship :Telephone Work : Telephone Home : Insurance informationPrimary insuranceDental coverage?YesNoInsurance Co. name:Address :StreetCityState ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipPhone : Group# (Plan, Local or Policy#):Insured’s name :Relationship :Birthday : SSN : Insured’s employer :Address :StreetCityState ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipSecondary insuranceDental coverage?YesNoInsurance Co. name:Address:StreetCityState ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipPhone: Group# (Plan, Local or Policy#):Insured’s name:Relationship:Birthday: SSN : Insured’s employer:Address:StreetCityState ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipMedical HistoryDo you have a personal physician? YesNoPhysician’s Name :Telephone home : Date of last visit : Your current physical health is :GoodFairPoorAre you currently under the care of a physician?YesNoExplain :Do you smoke or use tobacco in any other form?YesNoHave you had any metal rods, pins or implants?YesNoAre you taking any prescription / Over-the-counter drugs?YesNoHow many times per day :Medication name :Amount in milligrams :Have you ever taken Fosamax, or any other bisphosphonate?YesNoDo 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? YesNoAre you pregnant? YesNo Week # : Are you nursing? YesNoHave you ever had any of the following diseases or medical problemsYesNoAbnormal Bleeding / HemophiliaYesNoAIDS related complexYesNoAlcohol / Drug abuseYesNoAnemiaYesNoArthritisYesNoArtificial bones / Joints / ValvesYesNoAsthmaYesNoBlood transfusionYesNoChemotherapy (Center, leukemia)YesNoColitisYesNoCongenital heart defectYesNoDiabetesYesNoDifficulty breathingYesNoEmphysemaYesNoEpilepsy / seizuresYesNoExcessive bleedingYesNoRespiratory diseaseYesNoArtifical prosthesisYesNoCongenital heart diseaseYesNoX-Ray or cobalt treatmentYesNoFainting spells / seizuresYesNoFrequent headachesYesNoGlaucomaYesNoHay feverYesNoHeart attack / SurgeryYesNoHeart murmurYesNoHepatitis / jaundiceYesNoHerpes / Fever blistersYesNoHigh blood pressureYesNoAllergies or HivesYesNoHospitalized for any reasonYesNoKidney diseaseYesNoLiver diseaseYesNoLow blood pressureYesNoLupusYesNoAngina pectorisYesNoCerebral palsyYesNoJoint replacementYesNoNervous disorderYesNoTumors or growthsYesNoMitral valve prolapseYesNoPacemakerYesNoPsychiatric treatmentYesNoRadiation treatmentYesNoRheumatic / Scarlet feverYesNoShinglesYesNoSickle cell disease / TraitsYesNoSinus problemsYesNoStrokeYesNoThyroid problemsYesNoTuberculosis (TB)YesNoUlcersYesNoVenereal diseaseYesNoTonsillitisYesNoHead injuriesYesNoHeart failureYesNoChicken poxYesNoSinus TroubleYesNoBlood diseaseYesNoDrug addictionPlease list any serious medical condition(s) that you have ever had :Are you allergic to any of the following?YesNoAspirinYesNoPenicillinYesNoJewelry / MetalsYesNoAnesthetic (Novocain, ETC)YesNoDental anestheticsYesNoOtherYesNoErythromycinYesNoSulfa DrugsYesNoCodeineYesNoTetracyclineYesNoLatexPlease list any other drugs / Materials that you are allergic to :Dental HistoryWhy have you come to the dentist today? Are you currently in pain? YesNoDo you require antibiotics before dental treatment? YesNoYour current dental health is : GoodFairPoorHave you ever had a serious/difficult problem associated with any previous dental work? YesNoDo you floss daily? YesNoBrush daily? YesNoType of bristles on your toothbrush? HardMediumSoftHave you ever had gum treatment? YesNoDo your gums ever bleed? YesNoEver Itch? YesNoHave you ever had periodontal disease? YesNoDo you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? YesNoAre your teeth sensitive to Heat or Cold? HeatColdanything else? Do you have any loose teeth? YesNoDo you still have wisdom teeth? YesNoWould you like fresher breath? YesNoWhiter teeth? YesNoAre you happy with the way your smile looks? YesNoIf 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: