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New Patient Registration Form

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.


Patient first name :
Last Name :
I prefer to be called :
Gender : Male Female
 DOB : MM    DD    YYYY
 SS # :
If below 18 years, Parent/Guardian's name :
Marital Status :
Single Widowed
Married Divorced
Spouse name :
Home address :
City / State :
Zip :
Work phone :
Home Phone :
Cell phone :
Did you visit our website? Yes   No Employer : Occupation:
How did you find us ?:
Internet
Referred by
In case of emergency, contact : Phone # :
Insurance Information
Primary Insurance Co Name
   Secondary Insurance Co Name
  
Phone
Phone
Subscriber's Name
Subscriber's Name
Subscriber's SSN
Subscriber's SSN
Subscriber's Birthday
MM  DD    YYYY
   Subscriber's Birthday
MM  DD    YYYY
  
Subscriber's Employer
Subscriber's Employer
Health and Dental History
Physician's Name :
Phone :
Have you consulted an ENT (ear, nose and throat doctor) ? Yes   No Name :
Have you consulted a chiropactor ? Yes   No Name :
Have you consulted a neurologist ? Yes   No Name :
Have you ever worn braces ? Yes   No When :
Have you been under the care of a medical doctor during the past two years ? Yes   No
If so, list all surgeries
Date Type
In order to take good care of you, please list all medicines and supplements that you are currently taking. Include the doctor’s name who prescribed, self prescribed, herbal supplement, etc. All supplements have side effects. If you take it, we need to know.
Date Medicine or Supplement Dose Medical Condition Prescribing Doctor Notes
Indicate which of the following you have had, or have at present
Heart Attack Yes   No | Date : Headaches Yes   No
Stroke Yes   No | Date : Braces Yes   No
Congenital Heart Disease Yes   No Jaw Pain Yes   No
Heart Murmur Yes   No Jaw Popping Yes   No
Mitral Valve Prolapse Yes   No Limited Jaw Opening Yes   No
Artificial Heart Valve / Heart Bypass Yes   No | Date : Congested Ears Yes   No
Pacemaker Yes   No Dizziness Yes   No
Stents Yes   No | Date : Ringing Ears Yes   No
Rheumatic Fever Yes   No | Date : Loose Teeth Yes   No
High Blood Pressure Yes   No Bleeding Problems Yes   No
Diabetes Type1 Type2 Yes   No Posture Problems Yes   No
Hepatitis A B C D Yes   No Clenching Yes   No
AIDS / HIV Yes   No Grinding Yes   No
Tuberculosis Yes   No Facial Pain Yes   No
Kidney Trouble Yes   No Sensitive Teeth Yes   No
Psychiatric / Psychological Yes   No Neck Pain Yes   No
Epilepsy / Seizures Yes   No Bell's Palsy Yes   No
Asthma / Respiratory Disorder Yes   No Difficulty Swallowing Yes   No
Anemia / Blood Disorder Yes   No Difficulty Chewing Yes   No
Liver Disease / Jaundice Yes   No Trigeminal Neuralgia Yes   No
Sickle Cell Disease Yes   No Tingling in arms / fingers Yes   No
Neurological Disorders Yes   No Insomnia / Frequent waking Yes   No
Cancer Type : Date : Yes   No Artificial Joints Yes   No
Hip Date :
Knee Date :
Ankle Date :
Shoulder Date :
Radiation Yes   No    
Chemotherapy Yes   No    
Does the thread shred when you floss ? Yes   No
Do food particles catch between your teeth ? Yes   No
Do you smoke ? Yes   No
Do you use Chewing Tobacco? Yes   No
Do your gums bleed ? Yes   No
Does your breath concern you ? Yes   No
Allergies to any Medications
Penicillin Latex Codeine Metals Sulfa Food
Do you have or have had any disease, condition or problem not listed above ?
Have you ever undergone any cosmetic procedure(s) ? Yes   No
If yes please give details
Female Patients - Are you Pregnant ? Yes   No
  Nursing ? Yes   No
  Taking birth control pills ? Yes   No
By typing in my name, 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 the dentist 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 the dentist 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.
Typed Signature* : Date :
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