New Patient Registration

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 :  Male Female
*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?  Yes No
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? Yes No
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? Yes No
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?  Yes No
Physician’s Name :
Telephone home :

Date of last visit :

Your current physical health is : Good Fair Poor
Are you currently under the care of a physician? Yes No

Do you smoke or use tobacco in any other form? Yes No
Have you had any metal rods, pins or implants? Yes No
Are you taking any prescription / Over-the-counter drugs? Yes No

Have you ever taken Fosamax, or any other bisphosphonate? Yes No
Do you wear a cardiac pacemaker, or have you had heart surgery?  Yes No

If so, when?

Are you required to take any medication before your dental visit?  Yes No

If so, what?
For women :
Are you using a prescribed method of birth control?  Yes No
Are you pregnant?  Yes No Week # :
Are you nursing?  Yes No
Have you ever had any of the following diseases or medical problems
 Yes NoAbnormal Bleeding / Hemophilia
 Yes NoAIDS related complex
 Yes NoAlcohol / Drug abuse
 Yes NoAnemia
 Yes NoArthritis
 Yes NoArtificial bones / Joints / Valves
 Yes NoAsthma
 Yes NoBlood transfusion
 Yes NoChemotherapy (Center, leukemia)
 Yes NoColitis
 Yes NoCongenital heart defect
 Yes NoDiabetes
 Yes NoDifficulty breathing
 Yes NoEmphysema
 Yes NoEpilepsy / seizures
 Yes NoExcessive bleeding
 Yes NoRespiratory disease
 Yes NoArtifical prosthesis
 Yes NoCongenital heart disease
 Yes NoX-Ray or cobalt treatment
 Yes NoFainting spells / seizures
 Yes NoFrequent headaches
 Yes NoGlaucoma
 Yes NoHay fever
 Yes NoHeart attack / Surgery
 Yes NoHeart murmur
 Yes NoHepatitis / jaundice
 Yes NoHerpes / Fever blisters
 Yes NoHigh blood pressure
 Yes NoAllergies or Hives
 Yes NoHospitalized for any reason
 Yes NoKidney disease
 Yes NoLiver disease
 Yes NoLow blood pressure
 Yes NoLupus
 Yes NoAngina pectoris
 Yes NoCerebral palsy
 Yes NoJoint replacement
 Yes NoNervous disorder
 Yes NoTumors or growths
 Yes NoMitral valve prolapse
 Yes NoPacemaker
 Yes NoPsychiatric treatment
 Yes NoRadiation treatment
 Yes NoRheumatic / Scarlet fever
 Yes NoShingles
 Yes NoSickle cell disease / Traits
 Yes NoSinus problems
 Yes NoStroke
 Yes NoThyroid problems
 Yes NoTuberculosis (TB)
 Yes NoUlcers
 Yes NoVenereal disease
 Yes NoTonsillitis
 Yes NoHead injuries
 Yes NoHeart failure
 Yes NoChicken pox
 Yes NoSinus Trouble
 Yes NoBlood disease
 Yes NoDrug addiction
Please list any serious medical condition(s) that you have ever had :
Are you allergic to any of the following?
 Yes NoAspirin
 Yes NoPenicillin
 Yes NoJewelry / Metals
 Yes NoAnesthetic (Novocain, ETC)
 Yes NoDental anesthetics
 Yes NoOther
 Yes NoErythromycin
 Yes NoSulfa Drugs
 Yes NoCodeine
 Yes NoTetracycline
 Yes NoLatex
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?  Yes No
Do you require antibiotics before dental treatment?  Yes No
Your current dental health is :  Good Fair Poor
Have you ever had a serious/difficult problem associated with any previous dental work?  Yes No
Do you floss daily?  Yes No
Brush daily?  Yes No
Type of bristles on your toothbrush?  Hard Medium Soft
Have you ever had gum treatment?  Yes No
Do your gums ever bleed?  Yes No
Ever Itch?  Yes No
Have you ever had periodontal disease?  Yes No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?  Yes No
Are your teeth sensitive to Heat or Cold?  Heat Cold
anything else?
Do you have any loose teeth?  Yes No
Do you still have wisdom teeth?  Yes No
Would you like fresher breath?  Yes No
Whiter teeth?  Yes No
Are you happy with the way your smile looks?  Yes No
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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