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New Patient Registration Form
Print blank form to fill by hand

Please note we will review this form with you during your visit.

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

About you
*Patient last name :
Middle name : *First name :
If below 18 years of age;
Father’s name : Telephone #: ()--
Mother’s name : Telephone #: ()--
Other : Telephone #: ()--

I prefer to be called :
*Your birthday :
Age: Sex : MaleFemale Social security# :
*Home address :
City
State
Zip
APT#
*Email address :
Marital status : Single Married Widowed Divorced Separated Minor
Telephone :
*Home : ()--
Work : ()--ext:
Cell : ()--
Employer : Occupation :
Have you visited our website? YesNo Whom may we Thank for referring you?
How did you hear about us?
How would you like us to confirm appointments? Mark all that apply: Home   Work   Cell   E-mail  
Spouse/Partner information
His / Her name : Employer :
Work phone #: ()--ext:
Cell phone #: ()--
Birthday :
Social security# :
Nearest friend/relative to contact in case of emergency(not living with you)
His / Her name : Relationship :
Telephone :
Home : ()--
Work : ()--ext:
Insurance information
Primary insurance
Insurance Co. name:
Phone : ()--
Subscriber's name :
Relationship : Self Spouse Child
Subscriber's birthday :
Subscriber's SSN :
Subscriber's ID#:
Group#:
Subscriber's employer :
Secondary insurance
Insurance Co. name :
Phone : ()--
Subscriber's name :
Relationship : Self Spouse Child
Subscriber's birthday :
Subscriber's SSN :
Subscriber's ID#:
Group#:
Subscriber's employer :
Health and Dental History
Health problems and/or medications you are taking may make a difference in how we treat you to maintain your dental health.
Thanks for answering all of the following questions:
Physician's name : Phone # :
()--
Have you ever worn braces ? Yes  No
Have you been under the care of a medical doctor during the past two years ? Yes  No
Have you had any surgeries? If so, list all surgeries?
DateType
Have you ever taken Fosamax, Actonel, Boniva? Yes  No
Have you ever taken Phen-Fen or Redux? Yes  No
Have you ever experienced physical trauma to your upper body? Yes  No
Do you use tobacco products? Yes  No
When was your last visit to see the dentist/hygienist?
Have you consulted another health care provider(s) for this problem? Yes  No
Do your gums bleed ? Yes  No
Does your physician require prophylactic antibiotics (pre-medication) prior to dental care? Yes  No
Have you ever worn a night guard or mouth splint? Yes  No
In order to take good care of you, please list all medicines, (include over the counter products, and supplements) that you are currently taking. All supplements have side effects. If you take it, we need to know.
Medicine or Supplement Dose Medical condition Notes
Indicate which of the following you have had, or have at present

AIDS / HIV Yes   No
Hepatitis A B C D Yes   No
Mitral Valve Prolapse Yes   No
Artificial Joints Yes   No
Hip Date :
Knee Date :
Ankle Date :
Shoulder Date :
Heart Murmur Yes   No
Rheumatic Fever Yes   No | Date :
Anemia / Blood Disorder Yes   No
Asthma / Respiratory Disorder Yes   No
Artificial Heart Valve / Heart Bypass Yes   No | Date :
Alzheimer’s Disease Yes   No
Arthritis/Gout Yes   No
Bell's Palsy Yes   No
Bleeding Problems Yes   No
Blood Pressure High Low Yes   No
Cancer Yes   No
Type : | Date :
Chemotherapy Yes   No
Radiation Yes   No
Congenital Heart Disease Yes   No
Convulsions Yes   No
Cold Sores/Fever Blisters Yes   No
Diabetes Type1 Type2 Yes   No
Epilepsy / Seizures Yes   No
Frequent Coughing Yes   No
Genital Herpes Yes   No
Glaucoma Yes   No
Heart Attack Yes   No | Date :
Heart pacemaker Yes   No
Heart trouble/Disease Yes   No
Hayfever Yes   No
Herpes Yes   No
High Cholesterol Yes   No
Hypoglycemia Yes   No
Insomnia / Frequent waking Yes   No
Irregular Heartbeat Yes   No
Kidney problems Yes   No
Liver Disease / Jaundice Yes   No
Leukemia Yes   No
Lung Disease Yes   No
Neurological Disorders Yes   No
Psychiatric / Psychological Yes   No
Posture Problems Yes   No
Stroke Yes   No | Date :
Stents Yes   No | Date :
Sickle Cell Disease Yes   No
Shingles Yes   No
Tuberculosis Yes   No
Trigeminal Neuralgia Yes   No
Thyroid Disease Yes   No
Venereal Disease Yes   No
Congested Ears/Or Pain Yes   No
Clenching/Grinding Yes   No
Dizziness/Fainting spells Yes   No
Difficulty Swallowing/Chewing Yes   No
Facial Pain Yes   No
Headaches Yes   No
Jaw Pain Yes   No
Jaw Popping/Clenching/Clicking Yes   No
Neck Pain Yes   No
Ringing Ears Yes   No
Limited Jaw Opening Yes   No
Loose Teeth Yes   No
Sensitive Teeth Yes   No
Snoring Yes   No
Sleep Apnea Yes   No
Tingling in arms / fingers Yes   No
Temporalarteritis Yes   No
Allergies to any Medications
Penicillin Latex Codeine Metals Sulfa Food Aspirin Local Anesthetics
List Other Allergies
Do you have or have had any disease, condition or problem not listed above ?
Have you ever had any adult teeth extracted ? Yes   No
Female Patients - Are you Pregnant ? Yes   No
By typing (or signing) in my name

*Typed Signature
, I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all the questions to the best of my knowledge. I authorize Dr. Brossoit to release any information including the diagnosis and the records of any treatment or examination rendered to me, or my child, during the period of such dental care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to Dr. Brossoit insurance benefits, otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered to me or my dependents.
*I authorize Dr. Brossoit to use my picture/and or photos of my mouth and teeth for advertising and/or marketing in print or on our website
Date :
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