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Call: (909) 435 - 4558

303 Brookside Ave., Redlands, CA 92373

Dentist Redlands - Quality Dental Plan Banner

Rating: 5 Dentist Redlands - Five star reviews

Dr. Terry L. Vines Reviewed by Michele

I love Dr. Vines and the whole Pure Gold Dental staff. I would definitely recommend these caring and gentle people to any of my friends and family.

New Patient Registration Form

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

PATIENT INFORMATION:

*Name:

Last name

M.I.

First name

*Birthday :

Age:

*Email :

Social security# :

*Home address :

	City		State
	Zip		APT#

*Res. Phone :

()--

Cell phone:

()--

Work Phone :

()---

How long there ?

Occupation :

How did you hear about us?

Whom may we Thank for referring you?

Nearest relative not living with you

His / Her Name :

Relationship :

Phone :

()--

Address :

	City		State
	Zip		APT#

FINANCIAL INFORMATION: (Can skip address if its the same as patient information)

Person responsible: Relationship:

Phone :

()--

Birthday :

Address :

	City		State
	Zip		APT#

Occupation

Years with firm

Employer

Business Phone

()---

Social Security No.

Does this person have dental insurance? YesNo If so, is it through the employer? YesNo

Name of Dental Plan

Group No.

Local No.

Effective

Insurance limit per year?	$
Amount of annual deductible?	$
Amount of deductible paid this year?	$

SPOUSE/PARENT INFORMATION: (Can skip address if its the same as patient information)

Spouse or parent: Relationship:

Phone :

()--

Birthday :

Address :

	City		State
	Zip		APT#

Occupation

Years with firm

Employer

Business Phone

()---

Social Security No.

Does this person have dental insurance? YesNo If so, is it through the employer? YesNo

Name of Dental Plan

Group No.

Local No.

Effective

Insurance limit per year?	$
Amount of annual deductible?	$
Amount of deductible paid this year?	$

ADDITIONAL INFORMATION

If Patient is a student – Name of school attending City

Name of Physician:

Phone:

()--

Address:

	City		State
	Zip		APT#

Former Dentist

Phone

()--

Address :

	City		State
	Zip		APT#

IN CASE OF EMERGENCY CALL:

Relationship:

Phone:

()--

I, the undersigned, shall be responsible for the payment of charges incurred for all services rendered. I also agree to be responsible for the payment of all charges incurred in excess of existing insurance coverage.

HEALTH QUESTIONAIRE

Please answer each question. Check yes or no where applicable. This is for our records only.

MEDICAL HISTORY

1. Are you in good health?

Yes No

2. Date of last physical examination:

3. Are you now under the care of a Physician?

Yes No

4. Have you ever had a serious illness or operation?

Yes No

If so, explain:

5. Have you ever been hospitalized?

Yes No

If so, What was the problem?

6. Are you taking any drugs or medication?

Yes No

If so, What are you taking?

Antibiotics	Anticoagulants (Blood Thinners)	High Blood Pressure Medication
Aspirin	Street drugs or methadone	Other medications:

7. Are you sensitive or allergic to drugs/materials?

Yes No

If so, what? Sulfa drugs Codeine Aspirin Penicillins Antibiotics Latex
Other:

8. Do you have or have you had any of the following?

Yes/No
	AIDS/HIV
	Allergies
	Anemia
	Artificial Joints/Replacement
	Asthma or Hay Fever
	Blood Diseases
	Cancer
	Diabetes
	Epilepsy
	Excessive Bleeding/Transfusion
	Fainting spells or seizures
	Heart Ailments
	Head Injuries
	Heart Murmur/Mitral Valve Prolapse
	Hepatitis, Jaundice or Liver disease

Yes/No
	Blood Pressure High Low
	Kidney Disease
	Osteoporosis
	Mental Disorders
	Nervous Disorders
	Radiation treatment of any kind
	Respiratory Disease
	Rheumatic Fever
	Rheumatism or Arthritis
	Sinus Trouble
	Stroke
	Stomach Ulcers
	Tuberculosis
	Tumors or Growths
	Sexually Transmitted Diseases

9. Do you have a cardiac pacemaker?	Yes No
10. Have you ever used Fen/Phen?	Yes No
11. Have you had a heart valve or bypass surgery?	Yes No
12. Do you have a latex allergy?	Yes No
13. Are you being treated for or for prevention of osteoporosis?	Yes No
If YES, medication being taken?
14. WOMEN ONLY (Check if pertinent)
Pregnant/trying to get pregnant Nursing Taking Oral Contraceptives

OSTEOPOROSIS
15. Are you being treated for the prevention of osteoporosis?	Yes No
16. * Are you taking or scheduled to begin taking bisphosphonate medications such as alendronate (Fosamax^®) or risendronate(Actonel^®)?	Yes No
17. * Are you being treated or scheduled to begin intravenous bisphosphonates such as Aredia^® or Zometa^®?	Yes No

DENTAL HISTORY
18. Have you ever had a local anesthetic (Novocaine, etc.)?	Yes No
19. Have you ever had any unfavorable reaction from a local anesthetic?	Yes No
20. Have you ever had any serious trouble associated with any previous dental treatment?	Yes No
21. Does dental treatment make you nervous?	Yes No
22. How long since last dental x-rays of your entire mouth?
23. How long since last dental treatment? Last Cleaning?
24. Have you ever had excessive bleeding requiring treatment?	Yes No
25. Have you ever had instructions in the care of your teeth and gums?	Yes No

DO YOU HAVE OR DO YOU USE ANY OF THE FOLLOWING.

Yes/No
	Teeth sensitive to cold, heat, sweets or pressure
	Bleeding gums. How long?
	Food impaction
	Clenching or grinding
	Burning of tongue
	Swelling or lumps in mouth
	Pain around ear
	Bad breath
	Unpleasant taste
	Complications from extractions
	Periodontal (gums) treatment

Yes/No
	Orthodontic treatment
	Mouth breathing
	Oral Habits, i.e., fingernail biting cheek biting, etc.
	Cigarettes, pipe or cigar smoking
	Dental Floss
	Inter-dental stimulators
	Water jet device
	Disclosing tablets or solution
	Fluoride supplements
	Fluoride treatments

* CONSENT FOR TREATMENT:I hereby authorize the dentist to perform such dental operations or procedures and to administer such medications and/or drugs as may be deemed necessary or advisable in the diagnosis and treatment of this patient. Our staff includes dental auxiliaries who perform functions under the supervision of the dentist. I understand that the dentist will use his knowledge, skill and training to do his very best, but there is no guarantee of success of treatment. Treatment alternatives have been explained as well as the preferred method of treatment. I have been informed and I understand that occasionally there are complications with dental treatment, which have been explained for each procedure. I understand I can ask for a full recital of all possible risks attendant to treatment rendered. I understand my responsibility in maintaining good oral hygiene, following the dentist’s instructions, and keeping scheduled appointments. I have read and filled out the above information and confirm its accuracy.

***Authorization must be signed by the patient, or by the nearest relative in the case of a minor, or when the patient is physically or mentally incompetent.

*Signature :

Date :

Pure Gold Professionals in Dentistry Located at 303 Brookside Ave., Redlands, 92373, CA , . Phone: (909) 435 - 4558. http://www.puregolddental.com/.