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Call: (909) 435 - 4558
303 Brookside Ave., Redlands, CA 92373
Dentist Redlands - Quality Dental Plan Banner
Dentist Redlands - Care Credit
Rating: 5Dentist 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.
Dentist Redlands - Invisalign Logo

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     

DENTAL HISTORY
15. Have you ever had a local anesthetic (Novocaine, etc.)? Yes No
16. Have you ever had any unfavorable reaction from a local anesthetic? Yes No
17. Have you ever had any serious trouble associated with any previous dental treatment? Yes No
18. Does dental treatment make you nervous? Yes No
19. How long since last dental x-rays of your entire mouth?
20. How long since last dental treatment? Last Cleaning?
21. Have you ever had excessive bleeding requiring treatment? Yes No
22. 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 :