New Patient Registrations

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

General Information :
*Patient Last Name :
Middle Name :
*First Name :
*Your Birthday :
Age:
Sex : Male Female
Social Security# :
Marital Status : Single Married Separated
Divorced Widowed
Full time student? Yes No
*Home Address:
City :
State :
Zip :
Apt. # :
*Email address :
Driver’s license #:
*Home Phone : ()--
Cell Phone : ()--
Work Phone : ()---
Your Employer :
Occupation :
Spouse’s Name :
Spouse’s Birthday :
How did you hear about us?
Whom may we Thank for referring you
Reason for this visit :

Emergency Information :
Contact person of a relative not living with you.
Name :
Relationship :
Address :
City :
State :
Zip :
Apt. # :
Home Phone : ()--
Cell Phone : ()--

Dental Insurance Information :
Insured’s Name :
Insured’s Soc. Sec. #:
Insured’s Employer :
Insurance Co. :
Insurance Address :
City :
State :
Zip :
Insurance Phone : ()--
Insured’s ID #:

*If you have dual dental insurance coverage, complete the following section with the secondary insurance carrier information.
Insured’s Name :
Insured’s Soc. Sec. #:
Insured’s Employer :
Insurance Co. :
Insurance Address :
City :
State :
Zip :
Insurance Phone #: ()--
Insured’s ID #:

Medical History
Are you under the care of a physician ? Yes No
If yes, for what condition(s) ?
Physician’s Name :
Physician’s Phone #: ()--
Are you currently taking any medications ? Yes No
Please List :
Have you ever had the following :
Hospitalization for illness or injury Yes No
Allergic reaction to :
Penicillin Aspirin, ibuprofen, acetaminophen
Erythromycin Tetracycline
Codeine Local anesthetic
Fluoride Metals (gold, stainless steel, mercury)
Latex Any other medications
Heart problems Yes No
Heart murmur Yes No
Rheumatic fever Yes No
Scarlet fever Yes No
High blood pressure Yes No
Low blood pressure Yes No
A stroke Yes No
Artificial joint or heart valve Yes No
Anemia or other blood disorder Yes No
Prolonged bleeding when cut Yes No
Emphysema Yes No
Tuberculosis Yes No
Asthma Yes No
Sinus Problems Yes No
Kidney Disease Yes No
Liver Disease Yes No
Jaundice Yes No
Thyroid or parathyroid disease Yes No
Hormone deficiency Yes No
High cholesterol Yes No
Diabetes Yes No
Stomach or duodenal ulcer Yes No
Digestive disorders Yes No
Arthritis Yes No
Glaucoma Yes No
Cosmetic surgery Yes No
Hearing loss/hearing aid Yes No
Head or neck injuries Yes No
Epilepsy, Convulsions (seizures) Yes No
Viral infections and/or cold sores Yes No
Hives, skin rash, hay fever Yes No
Venereal disease Yes No
Hepatitis (Type : ) Yes No
HIV/AIDS Yes No
Tumor, abnormal growth Yes No
Radiation or chemotherapy Yes No
Emotional problems/psychiatric treatment Yes No
Antidepressant medication Yes No
Alcohol / drug dependency Yes No
Are you :
Often exhausted or fatigued Yes No
Subject to frequent headaches Yes No
A smoker, how many : Yes No
Male – prostate disorders Yes No
Female :
Taking birth control pills Yes No
Pregnant Yes No
Due Date :

Dental History
Previous Dentist :
How long :
Most recent dental exam :
Most recent dental x-rays :
Most recent dental treatment :
How often do you have your teeth cleaned ?
3mo / 4mo / 6mo / 1yr or more
What is your immediate dental concern ?

Please answer Yes Or No to the following
Unhappy with the appearance of your teeth Yes No
Would you like your smile to look better or different? Yes No
Teeth sensitive to temperature change Yes No
Problems with effectiveness or bad reactions to dental anesthetic? Yes No
Orthodontic treatment (braces): Yes No
When?
Periodontal (gum) treatment: Yes No
When?
Jaw problems (temporomandibular joint/TMJ) Yes No
Difficulty opening your mouth widely Yes No
Unpleasant taste or odor in your mouth Yes No
Burning sensation in your mouth Yes No
Bleeding gums Yes No
Dental fears: Yes No
Sore teeth Yes No
Difficulty swallowing Yes No
Dry mouth, throat, and/or eyes Yes No
Stiff neck muscles Yes No
Tension headaches Yes No
Clench or grind your teeth Yes No
Jaw clicking or popping Yes No
Lost any teeth Yes No

Denture History
( If you are wearing a partial or complete artificial denture, please complete the following )
When did you receive your first partial or complete denture ?
How long have you worn your present denture?
Has your present denture been relined ? Yes No
When ?
Is your present denture a problem ? Yes No
Describe :
Are you satisfied with the chewing ability ? Yes No

Consent :
* The undersigned hereby authorizes Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs.
* I also authorize Doctor to perform any and all forms of treatment, medication & therapy, that many be indicated.
* I also understand the use of anesthetic agents embodies a certain risk.
* I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered.
* I also assign all insurance benefits to the Doctor.

*Signature
Date