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
Allergies to any Medications
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.