Dentist Azusa - Phone icon
626-498-1766
310 N. Citrus Ave Suite A, Azusa, CA 91702
Dentist Azusa - Your care is in gentle hands

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
Name : *Last name  
Middle 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   Partnered   Divorced/Separated   Widowed
Work phone :
()---
*Home phone: ()--
Cell phone: ()--
Driver’s license # :
Employer :
How long there ? Occupation:
Employer address :
CityState
Zip
Apt. #
How did you hear about us? Whom may we thank for referring you?
Where & when are best times to reach you? Other family members seen by us:
Previous dentist:
Present dentist:  
Person responsible for account:

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

Emergency contact information for patient in case of an emergency
His / Her Name: Relationship:
Home telephone: ()- -
Work telephone: ()- - -
Insurance information
Primary insurance
Dental coverage? Yes No
Insurance Co. name:
Address:
Street
City
State   Zip
Phone: ()- -
Group# (Plan, Local or Policy#):
Insured’s name:
Relationship:
Birthday:
Social security#:
Insured’s employer:
Address:
Street
City
State   Zip
Secondary insurance
Dental coverage? Yes No
Insurance Co. name:
Address:
Street
City
State   Zip
Phone: ()- -
Group# (Plan, Local or Policy#):
Insured’s name:
Relationship:
Birthday:
Social security#:
Insured’s employer:
Address:
Street
City
State   Zip
Medical History
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
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
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
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   Other
Yes  No   Erythromycin
Yes  No   Sulfa drugs
Yes  No   Codeine
Yes  No   Tetracycline
Yes  No   Latex
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 Brush daily? Yes  No
Do you require antibiotics before dental treatment? Yes  No Have you ever had gum treatment? Yes  No
Your current dental health is: Good  Fair  Poor Do your gums ever bleed? Yes  No
Do you floss daily? Yes  No Ever Itch? Yes  No
Type of bristles on your toothbrush? Hard  Medium  Soft Have you ever had periodontal disease? Yes  No
Have you ever had a serious/difficult problem associated with any previous dental work?   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 Whiter teeth? Yes  No
Do you still have wisdom teeth? Yes  No Would you like fresher breath? Yes  No
Are you happy with the way your smile looks? Yes  No
If not, what would you change?

* I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor for scientific papers, promotional purposes or demonstrations.
* 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: