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Call: 828 684 1633
600 Julian Lane, Suite 610, Arden, NC 28704
Dentist Asheville, Cosmetic Dentist Asheville, Porcelain Veneers Asheville NC, Asheville Dentist
Dentist Asheville - Working Hours Office Hours
Monday-Thursday
8:30AM to 5:00PM
Fridays
9:00AM to 5:00PM
Dentist Asheville
More Than A Mouthful

"Dr. Chris Port, Asheville esthetic dentist and smile rejuvenator, recently signed a publishing deal with CelebrityPress, a leading health book publishing company along with other leading dental professionals from across the country to release the book, "More Than A Mouthful."

Press Release
Purchase this bookDentist Asheville
Dentist Asheville - FOY Logo
Our practice is trained in The Denture Fountain of Youth™ technique. Learn more about how The Denture Fountain of Youth™ work, their costs, and why they may be the right tooth replacement for you.

Patients Registration Form

Print blank form to fill by hand
Please note that it is important to fill in all the fields before submitting. Thank you.
ID: Chart ID:
*Name :
 *Last name

 Mid name

 *First name
Patient Is: Policy Holder Responsible Party
Preffered Name:
Responsible Party (If someone other than the patient)
Name :
 Last

 Mid initial

 First
Address :
City
State
Zip
Pager:
Address 2:
Home Phone: ()--
Work Phone: ()--Ext:
Cellular : ()--
Driver’s license# :
Birth Date :
Social security# :
Responsible Party is also a policy holder for patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder
Patient Information-
*Address :
City
State
Zip
Pager:
Address 2:
*Home Phone: ()--
Work Phone: ()--Ext:
Cellular: ()--
Driver’s license# :
Sex: Male Female
Marital Status : SingleMarriedPartneredDivorced/SeparatedWidowed
*Birth Date:
Age:
*Email address :
Social security# :
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:
Kid's Names :
Hobbies:
Pet's Names:
Primary Insurance Information-
Name of Insured:
Relationship to Insured: Self Spouse Child Other
Insured’s Birth Date:
Insured's Soc. Sec.#
Employer Details-
Employer:
Address :
City
State
Zip
Address 2:
Rem. Benefits: Rem. Deduct:
Insurance Company Details -
Ins. Company:
Address :
City
State
Zip
Address 2:
Secondary Insurance Information-
Name of Insured:
Relationship to Insured: Self Spouse Child Other
Insured’s Birth Date:
Insured's Soc. Sec.#
Employer Details-
Employer:
Address :
City
State
Zip
Address 2:
Rem. Benefits: Rem. Deduct:
Insurance Company Details -
Ins. Company:
Address :
City
State
Zip
Address 2:
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? YesNo
If Yes:
Have you ever been hospitalized or had a major operation? YesNo
If Yes:
Have you ever had a serious head or neck injury? YesNo
If Yes:
Are you taking any medications, pills or drugs? YesNo
If Yes:
Have you ever taken Fosamax,Boniva, Actonel or any other medications containing bisphosphonates? YesNo
If Yes:
Do you use tobacco? YesNo
Dental History
Are you currently in pain? YesNo
Do you require antibiotics before dental treatment? YesNo
Have you ever had a serious/difficult problem with any previous dental work? YesNo
Have you ever had gum treatment? YesNo
Do you floss daily? YesNo
Have you ever had periodontal disease? YesNo
Do your gums ever bleed or itch? YesNo
Do you have any loose teeth? YesNo
Do you still have wisdom teeth? YesNo
Did you wear braces? YesNo
Would you like fresher breath? YesNo
Do you now or have you ever experienced pain/discomfort in your jaw joints (TMD/TMJ)? YesNo
Are you happy with the way your smile looks? YesNo
If not, what would you change?
Women Are You :
Pregnant/Trying to get pregnant? YesNo
Nursing? YesNo
Taking oral contraceptives? YesNo
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Metal
Latex
Sulfa Drugs
Acrylic
Local Anesthetics
Other
Do you use controlled substances? YesNo
If Yes:
Do you have, or have you had,any of the following?
AIDS/HIV PositiveYesNo
DiabetesYesNo
Drug AddictionYesNo
HerpesYesNo
Arthritis/GoutYesNo
Hives or RashYesNo
Sickle Cell DiseaseYesNo
Sinus TroubleYesNo
LeukemiaYesNo
Liver Disease/JaundiceYesNo
Swelling of LimbsYesNo
ChemotherapyYesNo
Heart Attack/FailureYesNo
Heart Murmur YesNo
Heart PacemakerYesNo
Venereal DiseaseYesNo
HemophiliaYesNo
Hepatitis A/B/CYesNo
Renal DialysisYesNo
AnginaYesNo
Epilepsy / seizuresYesNo
Artifical Joint/ Heart valveYesNo
AsthmaYesNo
Blood DiseaseYesNo
Stomach/ Intestinal DiseaseYesNo
StrokeYesNo
CancerYesNo
Mitral Valve ProlapseYesNo
OsteoporosisYesNo
Pain in Jaw JointsYesNo
UlcersYesNo
LupusYesNo
Radiation TreatmentsYesNo
Recent Weight LossYesNo
AnemiaYesNo
Lung Disease/ EmphysemaYesNo
High CholesterolYesNo
Excessive ThirstYesNo
Fainting Spells/ DizzinessYesNo
Kidney ProblemsYesNo
Breathing ProblemsYesNo
Bruise EasilyYesNo
GlaucomaYesNo
TonsillitisYesNo
TuberculosisYesNo
Tumors or GrowthsYesNo
Heart Trouble/ diseaseYesNo
Anxiety/ Nervous DisorderYesNo
Alzheimer's DiseaseYesNo
AnaphylaxisYesNo
Easily WindedYesNo
High Blood PressureYesNo
Excessive BleedingYesNo
HypoglycemiaYesNo
Irregular HeartbeatYesNo
Spina BifidaYesNo
Frequent HeadachesYesNo
Low Blood PressureYesNo
Thyroid diseaseYesNo
Chest PainsYesNo
Cold Sores/ Fever BlistersYesNo
Congenital Heart DisorderYesNo
Psychiatric CareYesNo
Have you ever had any serious illness not listed: YesNo
* 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 :
Date :