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Patient Registration Form
Please note that it is important to fill in all the fields before submitting. Thank you.
Patient's name
*
:
DOB
:
SS #
:
If below 18 years, Parent/Guardian's name
:
Spouse name
:
Home address
:
City / State
:
Zip
:
Email
*
:
Home Phone
:
Cell phone
:
How did you find us
:
Work phone
:
Employer
:
In case of emergency, contact
:
Phone #
:
Health and Dental History
Physician's Name
:
Phone
:
Are you taking any medication now, including regular dosages of aspirin, vitamins, herbs, etc ?
Yes
No
If yes, please list name and dosage :
Are you allergic to any medications or substances ?
Yes
No
If so, please list :
Have you been under the care of a medical doctor during the past two years ?
Yes
No
If so, for what ?
Have you consulted an ENT (ear, nose and throat directory) ?
Yes
No
Name :
Have you consulted a chiropactor ?
Yes
No
Name :
Have you consulted a neurologist ?
Yes
No
Name :
Have you ever worn braces ?
Yes
No
When :
Indicate which of the following you have had, or have at present
Rheumatic Fever
Yes
No
Headaches
Yes
No
Heart Concerns
Yes
No
Braces
Yes
No
Congenital Heart Disease
Yes
No
Jaw Pain
Yes
No
Heart Murmur
Yes
No
Jaw Popping
Yes
No
High Blood Pressure
Yes
No
Limited Jaw Opening
Yes
No
Mitral Valve Prolepses
Yes
No
Congested Ears
Yes
No
Artificial Heart Valve
Yes
No
Dizziness
Yes
No
Pacemaker
Yes
No
Ringing Ears
Yes
No
Stroke
Yes
No
Loose Teeth
Yes
No
Asthma / Respiratory Disorder
Yes
No
Bleeding Problems
Yes
No
Anemia / Blood Disorder
Yes
No
Posture Problems
Yes
No
Liver Disease / Jaundice
Yes
No
Clenching
Yes
No
Tuberculosis
Yes
No
Grinding
Yes
No
Artificial Joints
Yes
No
Facial Pain
Yes
No
Kidney Trouble
Yes
No
Sensitive Teeth
Yes
No
Radiation / Chemotherapy
Yes
No
Neck Pain
Yes
No
Epilepsy / Seizures
Yes
No
Bell's Palsy
Yes
No
Diabetes
Yes
No
Difficulty Swallowing
Yes
No
Hepatitis A B C
Yes
No
Difficulty Chewing
Yes
No
AIDS / HIV
Yes
No
Trigeminal Neuralgia
Yes
No
Sickle Cell Disease
Yes
No
Tinglin in arms / fingers
Yes
No
Neurological Disorders
Yes
No
Insomnia / Frequent waking
Yes
No
Psychiatric / Psychological
Yes
No
Does the thread shred when you floss ?
Yes
No
Do food particles catch between your teeth ?
Yes
No
Do you smoke ?
Yes
No
Do you chew tobacco?
Yes
No
Do your gums bleed ?
Yes
No
Does your breath concern you ?
Yes
No
Penicillin
Latex
Codeine
Metals
Sulfa
Food
Do you have or have had any disease, condition or problem not listed above ?
Have you ever undergone any cosmetic procedure(s) ?
Yes
No
If yes please give details
Female Patients - Are you
Pregnant ?
Yes
No
Nursing ?
Yes
No
Taking birth control pills ?
Yes
No
This is to certify that I, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic as indicated and I will assume responsibility for fees associated with those procedures. I understand that my insurance is an agreement between my insurance company and me. I also understand that I am responsible for the balance of my account regardless of my insurance.
Patient (Parent's) Signature
:
Date
:
Marked
*
are required fields.