Patients Registration Form
Please note that it is important to fill in all the fields before submitting. Thank you.
Print blank form to fill by hand
ID
Chart ID
Name
*
First Name
Middle Name
Last Name
Patient Is
*
Policy Holder
Responsible Party
Preferred Name
Responsible Party
(If someone other than the patient)
Name
First Name
Middle Name
Last Name
Address
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Address 02
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cellular Number
Please enter a valid phone number.
Driver’s license Number
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
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13
14
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30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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2004
2003
2002
2001
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Social Security Number
Responsible Party is also a policy holder for patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder
Patient Information
Address
*
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Address 02
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cellular Number
*
Please enter a valid phone number.
Driver’s license Number
Sex
*
Please Select
Male
Female
Marital Status
Please Select
Single
Married
Partnered
Divorced
Separated
Widowed
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
Email Address
*
example@example.com
Social Security Number
I would like to receive correspondences via e-mail.
Section 02
Employment Status
Full Time
Part-Time
Retired
Student Status
Full Time
Part-Time
Medicaid ID
Employer ID
Carrier ID
Pref. Dentist
Pref. Pharmacy
Pref. Hyg
Section 03
Referral Source
Patient Value
Occupation
Spouse's Name
Spouse's Name
Kid's Names
Hobbies
Pet's Names
Primary Insurance Information
Name of Insured
Relationship to Insured
Self
Spouse
Child
Other
Insured’s Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Insured's Social Security Number
Employer Details
Employer
Address
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Address 02
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Rem. Benefits
Rem. Deduct
Insurance Company Details
Ins. Company
Address
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Address 02
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have Secondary Insurance?
*
Yes
No
Secondary Insurance Information
Name of Insured
Relationship to Insured
Self
Spouse
Child
Other
Insured’s Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Insured's Social Security Number
Employer Details
Employer
Address
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Address 02
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Rem. Benefits
Rem. Deduct
Insurance Company Details
Ins. Company
Address
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Address 02
Street Address, City, State, Zip, Pager
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Medical History
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication.
Are you under a physician care now?
*
Yes
No
If Yes Please Describe
*
Have you ever been hospitalized or had a major operation?
*
Yes
No
If Yes Please Describe
*
Have you ever had a serious head or neck injury?
*
Yes
No
If Yes Please Describe
*
Are you taking any medications, pills or drugs?
*
Yes
No
If Yes Please Describe
*
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
*
Yes
No
If Yes Please Describe
*
Do you use tobacco?
*
Yes
No
Dental History
Are you currently in pain?
*
Yes
No
Do you require antibiotics before dental treatment?
*
Yes
No
Have you ever had a serious/difficult problem with any previous dental work?
*
Yes
No
Have you ever had gum treatment?
*
Yes
No
Do you floss daily?
*
Yes
No
Have you ever had periodontal disease?
*
Yes
No
Do your gums ever bleed or itch?
*
Yes
No
Do you have any loose teeth?
*
Yes
No
Do you still have wisdom teeth?
*
Yes
No
Did you wear braces?
*
Yes
No
Would you like fresher breath?
*
Yes
No
Do you now or have you ever experienced pain/discomfort in your jaw joints (TMD/TMJ)?
*
Yes
No
Are you happy with the way your smile looks?
*
Yes
No
If not, what would you change?
*
Women Are You
Pregnant/Trying to get pregnant?
*
Yes
No
Nursing?
*
Yes
No
Taking oral contraceptives?
*
Yes
No
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Metal
Latex
Sulfa Drugs
Acrylic
Local Anesthetics
Other
Do you use controlled substances?
*
Yes
No
If Yes Please Describe
*
Do you have, or have you had, any of the following?
AIDS/HIV Positive
*
Yes
No
Diabetes
*
Yes
No
Drug Addiction
*
Yes
No
Herpes
*
Yes
No
Arthritis/Gout
*
Yes
No
Hives or Rash
*
Yes
No
Sickle Cell Disease
*
Yes
No
Sinus Trouble
*
Yes
No
Leukemia
*
Yes
No
Liver Disease/Jaundice
*
Yes
No
Swelling of Limbs
*
Yes
No
Chemotherapy
*
Yes
No
Heart Attack/Failure
*
Yes
No
Heart Murmur
*
Yes
No
Heart Pacemaker
*
Yes
No
Venereal Disease
*
Yes
No
Hemophilia
*
Yes
No
Hepatitis A/B/C
*
Yes
No
Renal Dialysis
*
Yes
No
Angina
*
Yes
No
Epilepsy / Seizures
*
Yes
No
Artificial Joint / Heart valve
*
Yes
No
Asthma
*
Yes
No
Blood Disease
*
Yes
No
Stomach / Intestinal Disease
*
Yes
No
Stroke
*
Yes
No
Cancer
*
Yes
No
Mitral Valve Prolapse
*
Yes
No
Osteoporosis
*
Yes
No
Pain in Jaw Joints
*
Yes
No
Ulcers
*
Yes
No
Lupus
*
Yes
No
Radiation Treatments
*
Yes
No
Recent Weight Loss
*
Yes
No
Anemia
*
Yes
No
Lung Disease / Emphysema
*
Yes
No
High Cholesterol
*
Yes
No
Excessive Thirst
*
Yes
No
Fainting Spells / Dizziness
*
Yes
No
Kidney Problems
*
Yes
No
Breathing Problems
*
Yes
No
Bruise Easily
*
Yes
No
Glaucoma
*
Yes
No
Tonsillitis
*
Yes
No
Tuberculosis
*
Yes
No
Tumors or Growths
*
Yes
No
Heart Trouble / Disease
*
Yes
No
Anxiety / Nervous Disorder
*
Yes
No
Alzheimer's Disease
*
Yes
No
Anaphylaxis
*
Yes
No
Easily Winded
*
Yes
No
High Blood Pressure
*
Yes
No
Excessive Bleeding
*
Yes
No
Hypoglycemia
*
Yes
No
Irregular Heartbeat
*
Yes
No
Spina Bifida
*
Yes
No
Frequent Headaches
*
Yes
No
Low Blood Pressure
*
Yes
No
Thyroid Disease
*
Yes
No
Chest Pains
*
Yes
No
Cold Sores / Fever Blisters
*
Yes
No
Congenital Heart Disorder
*
Yes
No
Psychiatric Care
*
Yes
No
Have you ever had any serious illness not listed
*
Yes
No
Please List
*
*
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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