Your browser doesn't support JavaScript or you have disabled JavaScript. You have to either update your browser or enable javascript on it in order to use this form.

Go Back How to enable JavaScript

Dental Patient Forms Miami - Smiling woman at Miami Modern Dental

New Patient Registration Form

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

About You

Title :

Mr. Mrs. Ms. Dr.

Patient Name :
	*Last Name :	Middle Name :	*First Name :

I prefer to be called :

Sex :

Male Female

*Your birthday :		Age:	SSN :
Marital Status :	Single Married Partnered Divorced/Separated Widowed

*Home Address :					City:
	State:		Zip:		Apt#:

*Email address :
*Home Phone:	()--	Work Phone:	()---
Cell Phone :	()--	Driver’s license# :
Employer :

Employer Address:					City:
	State:		Zip:		Apt#:

How long there ?		Occupation :
Previous dentist :		Present dentist :

Where & when are best times to reach you?
How did you hear about us?
Have you visited our website?	Yes No
Whom may we Thank for referring you?
Other family members seen by us :
Person responsible for account :

Spouse Information

His / Her name :	Employer :
Birthday :	SSN :
Driver’s license# :	Work Phone:	()---

Relative or friend not living with you

His / Her Name :		Relationship :
Home Phone :	()--	Work Phone :	()---

Medical History

Do you have a personal physician?

Yes No

Physician’s Name :
Date of last visit :		Home Phone:	()--

Your current physical health is :	Good Fair Poor
Are you currently under the care of a physician?	Yes No

If Yes, Please Explain :

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 / Over-the-counter drugs?	Yes No

If Yes, Please Explain :

Have you ever taken Fosamax, or any other bisphosphonate?	Yes No
Have you ever taken Phen-fen?	Yes No
Are you wearing contact lenses?	Yes No
Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?	Yes No
FOR WOMEN -
Are you using a prescribed method of birth control?	Yes No
Are you pregnant? Week # :	Yes No
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
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	Cancer / Chemotherapy
Yes No	Colitis
Yes No	Congenital heart defect
Yes No	Diabetes
Yes No	Difficulty breathing
Yes No	Emphysema
Yes No	Epilepsy / Convulsions
Yes No	Leukemia
Yes No	Angina
Yes No	Frequently Tired
Yes No	Fainting spells
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	HIV
Yes No	Hospitalized for any reason
Yes No	Kidney problems
Yes No	Liver disease
Yes No	Low blood pressure
Yes No	Lupus
Yes No	Sexually Transmitted Disease
Yes No	Chest Pains
Yes No	Easily Winded
Yes No	Mitral valve prolapse
Yes No	Pacemaker
Yes No	Psychiatric problems
Yes No	Radiation treatment
Yes No	Rheumatic / Scarlet fever
Yes No	Seizures
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	Stomach Troubles / Ulcers
Yes No	Venereal disease
Yes No	Swollen Ankles
Yes No	Recent Weight Loss
Yes No	Respiratory Problems

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	Local anesthetics (eg. novocaine)
Yes No	Sulfa Drugs
Yes No	Dental anesthetics
Yes No	Other

Yes No	Erythromycin
Yes No	Barbiturates
Yes No	Sedatives
Yes No	Codeine
Yes No	Tetracycline
Yes No	Latex
Yes No	Lodine

Please list any other drugs / Materials that you are allergic to :

Insurance Information

Primary Insurance

Dental coverage?	Yes No
Insurance Co. name:

Address :			City
	State		Zip

Phone :	()--	Group# :
Insured’s name :		Relationship :
Birthday :		SSN :
Insured’s Employer :

Address :			City
	State		Zip

Secondary Insurance

Dental coverage?	Yes No
Insurance Co. name:

Address :			City
	State		Zip

Phone :	()--	Group# :
Insured’s name :		Relationship :
Birthday :		SSN :
Insured’s Employer :

Insured’s Employer :

Address :			City
	State		Zip

Payment Is Due In Full At The Time Of Treatment

Unless prior arrangements have been approved.

If this office accepts insurance, I understand that I am responsible for payment of service rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all cost of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

Dental History

Why have you come to the dentist today?

Are you currently in pain?	Yes No
Are your teeth sensitive to sweet or sour liquids / foods?	Yes No
Do you feel pain to any of you teeth?	Yes No
Do you have any sores or lumps in or near your mouth?	Yes No
Have you had any head, neck or jaw injuries?	Yes No
Do you clench or grind your teeth?	Yes No
Have you had any orthodontic work?	Yes No
Have you ever had prolonged bleeding following extractions?	Yes No
Have you ever had instruction on the correct method of brushing your teeth?	Yes No
Have you ever had instructions on the care of your gums?	Yes No
Do you require antibiotics before dental treatment?	Yes No
Your current dental health is :	Good Fair Poor
Have you ever had a serious/difficult problem associated with any previous dental work?	Yes No
Do you floss daily?	Yes No
Brush daily?	Yes No
Type of bristles on your toothbrush? Hard Medium Soft
Have you ever had gum treatment?	Yes No
Do your gums ever bleed?	Yes No
Ever Itch?	Yes No
Have you ever had periodontal disease?	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
Do you still have wisdom teeth?	Yes No
Would you like fresher breath?	Yes No
Whiter teeth?	Yes No
Are you happy with the way your smile looks?	Yes No
If Not, what would you change?

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.