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Evans Dental Care

Home

Meet the Staff

Get Directions

Why Choose Us?

Call Today 757-349-8877

103 Bulifants Blvd, Suite B
Williamsburg, VA 23188

BioCompatible Dental Care ... always safe for you

New Patient Registration

Please note that it is important to fill in all the fields before submitting. Thank you.

*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 Divorced/Separated Widowed

Business #:

()---

*Home phone #:

()--

Cell phone#:

()--

Occupation :

Employer:

How did you hear about us?

Whom may we thank for referring you?

In case of emergency, notify(other than spouse):

Phone #:

()--

Relation :

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 #:

Business phone #:

()---

Home phone #:

()--

Address:

	City		State
	Zip

Relationship to patient:

Employer name:

Employer Address:

	City		State
	Zip

Financial policy

Services must be paid at the time of SERVICE. Cash, check or VISA/MasterCard is accepted
A $25.00 charge will be added to your balance for each returned check.
Filing insurance claims is a service provided free and in no way relieves you of responsibility of your bill.
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.	Date of your last dental appointment? 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? How often?	Yes No
15.	How often do you brush your teeth?

Children only

01.

Are your child's immunizations up to date?

If not, please explain :

Yes No

02.

Name, age and sex of other children in the family:

Name :	Age :	Sex : Male Female
Name :	Age :	Sex : Male Female
Name :	Age :	Sex : 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?

How often?

Yes No

06.

Does your child use dental floss?

Yes No

07.

Does your child eat between meal snacks?

How many times?

Yes No

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 list :
	b. Do you take any alternative medications (supplements/herbs/vitamins)?	Yes No
	Please list :

04.

Do you have or have you had any of the following diseases or problems?

Rheumatic Fever	YesNo
Scarlet Fever	YesNo
Heart Attack or Stroke	YesNo
High blood pressure	YesNo
Heart Murmur	YesNo
Thyroid Disease	YesNo
AIDS, AIDS Related Complex or HIV	YesNo

Kidney Disease	YesNo
Asthma or Hay Fever	YesNo
Venereal Disease (Herpes,Syphilis,Gonorrhea)	YesNo
Tuberculosis (T.B)	YesNo
Seizures (Epilepsy, Fits, Convulsions)	YesNo
Hepatitis, Yellow Jaundice	YesNo

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 :

Evans Dental Care Located at 103 Bulifants Blvd, Suite B Williamsburg, VA, 23188 Phone: 757-349-8877 www.evansdentalcare.com