Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.
About you
Title : MrMrsMsDr
*Last name :
Middle name : *First name :
I prefer to be called : Sex : MaleFemale
*Your birthday :
Age:
SSN :
*Home address :
City
State
Zip
APT#
*Email address :
Marital Status : SingleMarriedPartneredDivorced/SeparatedWidowed
Telephone :
*Home : ()--
Work : ()---
Cell : ()--
Driver’s license number :
Employer :
Employer address :
CityState
Zip
APT#
How long there ? Occupation :
Where & when are best times to reach you?
How did you hear about us? Have you visited our website? YesNo
Whom may we Thank for referring you?
Other family members seen by us :
Previous dentist : Present dentist :
Person responsible for account :
Spouse information
His / Her name : Employer :
Birthday : SSN :
Driver’s license number : Telephone work : ()---
Relative or friend not living with you
His / Her Name : Relationship :
Telephone :
Home : ()--
Work : ()---
Medical History
Do you have a personal physician? YesNo
Physician’s Name :
Telephone home :
()--
Date of last visit :
Your current physical health is : GoodFairPoor
Are you currently under the care of a physician? YesNo
Do you smoke or use tobacco in any other form? YesNo
Have you had any metal rods, pins or implants? YesNo
Are you taking any prescription / Over-the-counter drugs? YesNo
Have you ever taken Fosamax, or any other bisphosphonate? YesNo
Have you ever taken Phen-fen? YesNo
For women :
Are you using a prescribed method of birth control? YesNo
Are you pregnant? YesNo Week # :
Are you nursing? YesNo
Have you ever had any of the following diseases or medical problems
YesNoAbnormal Bleeding / Hemophilia
YesNo AIDS
YesNo Alcohol / Drug abuse
YesNo Anemia
YesNo Arthritis
YesNo Artificial bones / Joints / Valves
YesNoAsthma
YesNoBlood transfusion
YesNoCancer / Chemotherapy
YesNoColitis
YesNo Congenital heart defect
YesNoDiabetes
YesNo Difficulty breathing
YesNo Emphysema
YesNo Epilepsy
YesNo Fainting spells
YesNo Frequent headaches
YesNo Glaucoma
YesNo Hay fever
YesNo Heart attack / Surgery
YesNo Heart murmur
YesNo Hepatitis
YesNo Herpes / Fever blisters
YesNo High blood pressure
YesNo HIV
YesNo Hospitalized for any reason
YesNo Kidney problems
YesNo Liver disease
YesNo Low blood pressure
YesNo Lupus
YesNo Mitral valve prolapse
YesNo Pacemaker
YesNo Psychiatric problems
YesNo Radiation treatment
YesNo Rheumatic / Scarlet fever
YesNo Seizures
YesNo Shingles
YesNo Sickle cell disease / Traits
YesNo Sinus problems
YesNo Stroke
YesNo Thyroid problems
YesNo Tuberculosis (TB)
YesNo Ulcers
YesNo Venereal disease
Please list any serious medical condition(s) that you have ever had :
Are you allergic to any of the following?
YesNoAspirin
YesNoPenicillin
YesNoJewelry / Metals
YesNoDental anesthetics
YesNoOther
YesNoErythromycin
YesNoCodeine
YesNoTetracycline
YesNoLatex
Please list any other drugs / Materials that you are allergic to :
Insurance information
Primary insurance
Dental coverage? YesNo
Insurance Co. name:
Address :
Street
City
State
Zip
Phone : ()--
Group# (Plan, Local or Policy#):
Insured’s name :
Relationship :
Birthday :
SSN :
Insured’s Address :
Street
City
State
Zip
Insured’s Phone : ()--
Insured’s employer :
Address :
Street
City
State
Zip
Secondary insurance
Dental coverage? YesNo
Insurance Co. name :
Address :
Street
City
State
Zip
Phone : ()--
Group# (Plan, Local or Policy#):
Insured’s name :
Relationship :
Birthday :
SSN :
Insured’s Address :
Street
City
State
Zip
Insured’s Phone : ()--
Insured’s employer :
Address :
Street
City
State
Zip
Payment is due in full at the time of treatment
Unless prior arrangements have been approved.
*If this office accepts insurance, I understand that I am responsible for payment of service rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all cost of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Dental history
Why have you come to the dentist today?
Are you currently in pain? YesNo
Do you require antibiotics before dental treatment? 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?
*I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.
*Signature :
Date :