New Patient Registration Form

About you

Title:
Mr
Mrs
Ms
Dr
Patient Name: *


I prefer to be called:
Your birthday: *
Age:
Sex:
Male Female
Social security #:
Home address: *
Email address: *
Marital Status:
Single
Married
Divorced/Separated
Widowed
Home phone: *
( ) - -
Cell phone:
( ) - -
Work phone:
( ) - - -
Driver’s license#:
Employer:
Address:
How long there?
Occupation:
Where & when are best times to reach you?
How did you hear about us?
Whom may we thank for referring you?
Other family members seen by us:
Previous dentist's name :
Present dentist's name :
Person responsible for account:

Spouse information

His / Her name:
Birthday:
Employer:
Social security #:
Telephone work:
( ) - - -
Driver’s license #:

Emergency contact information for patient in case of an emergency

His / Her Name:
Relationship:
Home telephone:
( )- -
Work telephone:
( )- - -

Insurance information

Dental coverage?
Yes No
Insurance Company:
Address:
In. Company phone:
( )- -
Group#:
Insured’s name:
Relationship:
Birthday:
Social security #:
Insured’s employer:
Address:

Medical History

Do you have a medical condition that requires you to take antibiotics before dental treatment? such as : Jiont Replacement Surgeries, Heart Valve Replacements, Organ Transplant... If So Please Explain :
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
Please explain:
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 or over-the-counter drugs?
Yes No
Please explain:
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
When?
Are you required to take any medication before your dental visit?
Yes No
What?
Have you had any joint replacement surgeries?
Yes No
Please Explain : (list the medication you are currently taking)
Have you had any heart valve replacement surgeries?
Yes No
Please Explain :
For women: Are you using a prescribed method of birth control?
Yes No
For women: Are you pregnant?
Yes No
Week #:
For women: Are you nursing?
Yes No

Have you ever had any of the following diseases or medical problems

Yes No Abnormal Bleeding / Hemophilia
Yes No AIDS related complex
Yes No Alcohol / Drug abuse
Yes No Anemia
Yes No Arthritis
Yes No Artificial bones / Joints / Valves
Yes No Asthma
Yes No Blood transfusion
Yes No Chemotherapy (Cancer, leukemia)
Yes No Colitis
Yes No Congenital heart defect
Yes No Diabetes
Yes No Difficulty breathing
Yes No Emphysema
Yes No Epilepsy / seizures
Yes No Excessive bleeding
Yes No Respiratory disease
Yes No Artifical prosthesis
Yes No Congenital heart disease
Yes No X-Ray or cobalt treatment
Yes No Fainting spells / seizures
Yes No Frequent headaches
Yes No Glaucoma
Yes No Hay fever
Yes No Heart attack / surgery
Yes No Heart murmur
Yes No Hepatitis / jaundice
Yes No Herpes / fever blisters
Yes No High blood pressure
Yes No Allergies or Hives
Yes No Hospitalized for any reason
Yes No Kidney disease
Yes No Liver disease
Yes No Lupus
Yes No Angina pectoris
Yes No Cerebral palsy
Yes No Joint replacement
Yes No Nervous disorder
Yes No Tumors or growths
Yes No Mitral valve prolapse
Yes No Pacemaker
Yes No Psychiatric treatment
Yes No Radiation treatment
Yes No Rheumatic / Scarlet fever
Yes No Shingles
Yes No Sickle cell disease / Traits
Yes No Sinus problems
Yes No Stroke
Yes No Thyroid problems
Yes No Tuberculosis (TB)
Yes No Ulcers
Yes No Tonsillitis
Yes No Head injuries
Yes No Heart failure
Yes No Chicken pox
Yes No Blood disease
Yes No Drug addiction
Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

Yes No Aspirin
Yes No Penicillin
Yes No Jewelry / Metals
Yes No Anesthetic (Novocain, etc.)
Yes No Dental anesthetics
Yes No Mercury
Yes No Erythromycin
Yes No Sulfa drugs
Yes No Codeine
Yes No Tetracycline
Yes No Latex
Yes No Other
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
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 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?
*
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