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(336) 600-1179
Virtue Dental Care, 301 East Lee Avenue
Yadkinville, NC 27055

New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.
About you
Title: Mr Mrs Ms Dr
*Patient Name:
  *Last name

  Mid name

  *First name
I prefer to be called:
*Your birthday:
Age: Sex: Male Female
Social security#:
*Home address:
City
State
Zip
Apt.#
*Email address:
Marital Status: Single Married Divorced/Separated Widowed
*Home phone: ()--
Cell phone: ()--
Work phone: ()---
Driver’s license#:
Employer:
Address:
City
State Zip
Apt.#
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? YesNo
Insurance company name:
Insurance company address:
Street
City
State
Zip
Insurance company phone: ()--
Group#(Plan, Local or Policy#)
Insured’s name:
Relationship:
Birthday:
Social security number:
Insured’s employer:
Insured’s employer address:
Street
City
State
Zip
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: GoodFairPoor
Are you currently under the care of a physician? Yes No
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
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
Are you required to take any medication before your dental visit? Yes No
Have you had any joint replacement surgeries? Yes No
Have you had any heart valve replacement surgeries? Yes No
For women:
Are you using a prescribed method of birth control? Yes No
Are you pregnant? Yes No Week #:
Are you nursing? Yes No
Have you ever had any of the following diseases or medical problems
YesNoAbnormal Bleeding / Hemophilia
YesNo AIDS related complex
YesNo Alcohol / Drug abuse
YesNo Anemia
YesNo Arthritis
YesNo Artificial bones / Joints / Valves
YesNoAsthma
YesNoBlood transfusion
YesNoChemotherapy (Cancer, leukemia)
YesNoColitis
YesNo Congenital heart defect
YesNoDiabetes
YesNo Difficulty breathing
YesNo Emphysema
YesNo Epilepsy / seizures
YesNo Excessive bleeding
YesNo Respiratory disease
YesNo Artifical prosthesis
YesNo Congenital heart disease
YesNo X-Ray or cobalt treatment
YesNo Fainting spells / seizures
YesNo Frequent headaches
YesNo Glaucoma
YesNo Hay fever
YesNo Heart attack / surgery
YesNo Heart murmur
YesNo Hepatitis / jaundice
YesNo Herpes / fever blisters
YesNo High blood pressure
YesNo Allergies or Hives
YesNo Hospitalized for any reason
YesNo Kidney disease
YesNo Liver disease
YesNo Lupus
YesNo Angina pectoris
YesNo Cerebral palsy
YesNo Joint replacement
YesNo Nervous disorder
YesNo Tumors or growths
YesNo Mitral valve prolapse
YesNo Pacemaker
YesNo Psychiatric treatment
YesNo Radiation treatment
YesNo Rheumatic / Scarlet fever
YesNo Shingles
YesNo Sickle cell disease / Traits
YesNo Sinus problems
YesNo Stroke
YesNo Thyroid problems
YesNo Tuberculosis (TB)
YesNo Ulcers
YesNoTonsillitis
YesNoHead injuries
YesNoHeart failure
YesNoChicken pox
YesNoBlood disease
YesNoDrug addiction
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
YesNoAspirin
YesNoPenicillin
YesNoJewelry / Metals
YesNoAnesthetic (Novocain, etc.)
YesNoDental anesthetics
YesNoMercury
YesNoErythromycin
YesNoSulfa drugs
YesNoCodeine
YesNoTetracycline
YesNoLatex
YesNoOther
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? YesNo
Your current dental health is: GoodFairPoor
Have you ever had a serious/difficult problem associated with any previous dental work? YesNo
Do you floss daily? YesNo
Brush daily? YesNo
Type of bristles on your toothbrush? HardMediumSoft
Have you ever had gum treatment? YesNo
Do your gums ever bleed? YesNo
Ever Itch? YesNo
Have you ever had periodontal disease? YesNo
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? YesNo
Are your teeth sensitive to: HeatCold
anything else?
Do you have any loose teeth? YesNo
Do you still have wisdom teeth? YesNo
Would you like fresher breath? YesNo
Whiter teeth? YesNo
Are you happy with the way your smile looks? YesNo
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: