New Patient Registration

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

Is this patient registration for : You Your child
Patient Name :
*Last Name:
 Middle Name: *First Name:
*Your birthday :
Sex: Male Female SS# :
Marital Status : Single Married Divorced/Separated Widowed DL #:
*Home address :
City :
State :
Zip :
Apt# :
*Email address :
*Home Phone : ()--
Cell# : ()--
Work# : ()---
Do you receive text messages on your cell? Yes No
Who will pay this account :
Employed By :
Business address : City :
State : Zip :
Emergency Contact Details (not at same address) -
His/Her Name : Phone # : ()--
Address : City :
State : Zip :
Apt# :
Whom may we thank for referring you? Yellow Pages Internet Friend/Family
Other :
Spouse's Details -
Spouse's Name :
Last Name: Middle Name: First Name:
Birthday :
SS# :
DL #:
Marital Status : Single Married Divorced/Separated Widowed
Home address : City :
State : Zip :
Apt# :
Email address :
Home Phone : ()--
Cell# : ()--
Work# : ()---
Employed By :
How Long?    Hourly Salary Retired
Business address : City :
State : Zip :
Primary Dental Insurance Details -
Insurance Company : Compay Phone # : ()--
Mailing address : City :
State : Zip :
Contract ID/S.S. #:
Service code: Group #:
Secondary Dental Insurance Details -
Insurance Company : Compay Phone # : ()--
Mailing address : City :
State : Zip :
Contract ID/S.S. #:
Service code: Group #:
Medical Insurance Details -
Insurance name : Blue Cross Medicare Other : Group #:
Subscriber name: Service code:
Health History
I. Select appropriate answer
01. Is your general health good? Yes No
02. Has there been a change in your health within the last year? Yes No
03. Have you been hospitalized or had a serious illness in the last three years? Yes No
If Yes, explain?
04. Are you being treated by a physician now? Yes No
For what?
Physician’s Name :
Phone #: ()--
Last Dental Exam :
05. Are you in pain now? Yes No
If Yes, explain?

II. Do you have or have you had:
06. Heart disease? Yes No 07. Heart attack? Yes No
08. Prosthetic heart valve? Yes No 09. Heart murmur? Yes No
10. Pacemaker? Yes No
If YES on any of the above: Treating Physician’s Details -
Name :
Phone #: ()--
11. Stroke, hardening of arteries? Yes No 12. Rheumatic fever? Yes No
13. Asthma, TB, emphysema, other lung disease? Yes No 14. High blood pressure? Yes No
15. Hepatitis, other liver disease? Yes No 16. Psychiatric care? Yes No
17. Radiation treatments or Chemotherapy? Yes No 18. Chemotherapy? Yes No
19. Artificial joint? Yes No 20. Tumors, cancer? Yes No
21. VD (syphilis/gonorrhea)? Yes No 22. Anemia? Yes No
23. Kidney, bladder disease? Yes No 24. Herpes? Yes No
25. Thyroid, adrenal disease? Yes No 26. Diabetes? Yes No
27. HIV/AIDS? Yes No 28. Hospitalization? Yes No
29. Blood transfusions? Yes No 30. Osteoporosis? Yes No
31. Arthritis, rheumatism? Yes No
32. Allergies to: drugs, food, medications, latex, nickel? Yes No
If YES please list :

III. Are you taking:
33. Recreational drugs? Yes No
34. Drugs, medications, over-the-counter medicines (including aspirin), natural remedies? Yes No
If YES please list :
35. Tobacco in any forms? If Yes, how much : Yes No
36. Alcohol? If Yes, how often : Yes No

IV. Women only:
37. Are you or could you be pregnant or nursing? Yes No 38. Taking birth control pills? Yes No

V. All patients:
39. Is there anything else you think we should be aware of? Yes No
Please list :

* To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.

*Signature :
Date :