Click on Calendar, type the year "YYYY" and pick the month & date.
 
≣ MENU
757-349-8877
Evans Dental Care

New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.
*Patient Last Name :
Middle Name :
*First Name :
*Home Address:
City :
State :
Zip :
Apt. # :
*Your birthday:
Age:
Sex: Male Female
Social security #:
*Email address:
Marital Status: Single Married
Partnered Widowed
Divorced/Separated
*Home phone #: ( )- -
Cell phone#: ( )- -
Business #: ( )- - -
Occupation :
Employer:
How did you hear about us?
Whom may we thank for referring you?
In case of emergency, notify(other than spouse):
Contact Name :
Relationship :
Phone #: ( )- -
Financial arrangements
I have no dental insurance: I elect to pay:
Cash
Check
MasterCard/VISA on all visits.
I have dental insurance.
Insured's Last name:
Insured's First name:
Insurance carrier :
Relation to insured :
Policy No :
Group No :
Address :
City :
State :
Zip :
Person responsible for account :
Social security #:
Address :
City :
State :
Zip :
Home phone #: ( )- -
Business phone #: ( )- - -
Relationship to patient:
Employer name:
Employer Address :
City :
State :
Zip :
Financial policy
  1. Services must be paid at the time of SERVICE. Cash, check or VISA/MasterCard is accepted
  2. A $25.00 charge will be added to your balance for each returned check.
  3. Filing insurance claims is a service provided free and in no way relieves you of responsibility of your bill.
  4. Your appointments are scheduled with Dr. Evans to reserve time for you in a predictable manner. Broken or cancelled appointments may be charged at full fee unless 24 hours notice is given to our office. Insurance carriers do not cover broken or cancelled appointments. A phone call to us will be help avoid this charge.
* I have read this form and hereby certify that the information on this registration is correct.
Dental History
01. What is your chief dental complaint?
02. Last dental Appointment :
Date :
With whom?
03. Have you ever had any injury to your face or jaws? Yes No
04. Have you every had abnormal bleeding following dental extractions? Yes No
05. Do you have sensitive teeth? Yes No
06. Have you ever had dental surgery for a tumor, growth or other condition in your mouth or on your lips? Yes No
07. Does your jaw hurt or make noise when you chew or open wide? Yes No
08. Do you have pain in the area of your ears? Yes No
09. Do you smoke or use tobacco in any form? Yes No
10. Have you ever been treated for periodontal (gum) disease? Yes No
11. Do you clench or grind your teeth together? Yes No
12. Are you dissatisfied with the appearance of your teeth? Yes No
13. Do you use fluoride toothpaste? Yes No
14. Do you floss your teeth? Yes No
How often?
15. How often do you brush your teeth?
Children only
01. Are your child's immunizations up to date? Yes No
If not, please explain :
02. Name, age and sex of other children in the family:
Name Age Sex
Male Female
Male Female
Male Female
03. Pets, hobbies and special interests :
04. Is this your child's first dental visit? Yes No
If not, have you been pleased with your child's past dental care? Yes No
05. Does your child brush his/her teeth? Yes No
How often?
06. Does your child use dental floss? Yes No
07. Does your child eat between meal snacks? Yes No
How many times?
08. Does your child eat snacks high in sugar? Yes No
09. Has your child had fluoride in any of the following forms?
Drinking water Toothpaste with fluoride
Topical (painted on teeth) Prescribed fluoride tablet or liquid
10. Does your child have any of the following habits?
Grinding teeth Lip sucking or biting
Tongue thrusting Thumb or finger sucking
Nail biting Constant mouth breathing
MEDICAL HISTORY – CONFIDENTIAL
Height :
Weight :
Date of Last Exam :
Physician name:
Physician Phone #: ( )- -
Physician Address :
City :
State :
Zip :
01. Are you under the care of a physician? Yes No
What is the condition(s) being treated?
02. Have you ever been a patient in a hospital? Yes No
Please Explain :
03. a. Have you been prescribed medications in the past 6 months/are you taking any medications now? Yes No
Please Explain :
03. b. Do you take any alternative medications (supplements/herbs/vitamins)? Yes No
Please Explain :
04. Do you have or have you had any of the following diseases or problems?
Rheumatic Fever Yes No
Scarlet Fever Yes No
Heart Attack or Stroke Yes No
High blood pressure Yes No
Heart Murmur Yes No
Thyroid Disease Yes No
AIDS, AIDS Related Complex or HIV   Yes No
Kidney Disease Yes No
Asthma or Hay Fever Yes No
Venereal Disease (Herpes,Syphilis,Gonorrhea)   Yes No
Tuberculosis (T.B) Yes No
Seizures (Epilepsy, Fits, Convulsions) Yes No
Hepatitis, Yellow Jaundice Yes No
05. Have you been tested for an allergy to Mercury in your silver mercury fillings? Yes No
06. Is your immune system suppressed or compromised? Yes No
07. Have you ever had anemia, low blood or thin blood? Yes No
08. Have you ever taken medication to thin your blood? Yes No
09. Have you ever had a blood transfusion? Yes No
10. Do you bleed longer or bruise more easily than other people? Yes No
11. Do you have pain in your chest upon exertion? Yes No
12. Do you get short of breath when lying down, require more than one pillow or use a CPAP when sleeping? Yes No
13. Have you or any member of your family ever had diabetes? Yes No
14. Do you frequently get a dry mouth, become thirsty, or urinate more than six (6) times a day? Yes No
15. Do you have any allergies to food, medicine, etc.? Yes No
16. Have you been told not to take PENICILLIN or Novocain? Yes No
17. Have you ever been treated for, or taken medication for an emotional problem or for your nerves? Yes No
18. Have you ever had a stomach, duodenal, or peptic ulcer? Yes No
19. Have you ever had radiation (X-ray) treatment or chemotherapy for any disease? Yes No
20. Have you ever been given cortisone treatment? Yes No
Females Only :
Are you taking birth control pills? Yes No
Are you pregnant? Yes No
If yes, when is your expected due date?
*e-Signature
Date

Home | Meet the Staff | Patient Reviews | Picture Gallery | New Patient Forms | Free Reports | Contact Us | Sitemap| My Google+
Evans Dental Care Located at 103 Bulifants Blvd, Suite B Williamsburg, VA, 23188 Phone: 757-349-8877
© Copyrights 2024 Evans Dental Care. All rights reserved. Powered by : www.ekwa.com