New Patient Registration

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

General Information :
*Last Name :
Middle Name : *First Name :
*Your Birthday :
Age: Sex : MaleFemale   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 #:
Telephone :
*Home : ()--
Work : ()---
Cell : ()--
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. #:
Insurance Co. : Insured’s ID #:
Insurance Co. Address :
City State
Zip
Insurance Phone #: ()--
Insured’s Employer :

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

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 injuryYesNo
Allergic reaction to
Penicillin Aspirin, ibuprofen, acetaminophen
Erythromycin Tetracycline
Codeine Local anesthetic
Fluoride Metals (gold, stainless steel, mercury)
Latex Any other medications
Heart problems YesNo
Heart murmur YesNo
Rheumatic fever YesNo
Scarlet fever YesNo
High blood pressure YesNo
Low blood pressure YesNo
A stroke YesNo
Artificial joint or heart valve YesNo
Anemia or other blood disorder YesNo
Prolonged bleeding when cut YesNo
Emphysema YesNo
Tuberculosis YesNo
Asthma YesNo
Sinus Problems YesNo
Kidney Disease YesNo
Liver Disease YesNo
Jaundice YesNo
Thyroid or parathyroid disease YesNo
Hormone deficiency YesNo
High cholesterol YesNo
Diabetes YesNo
Stomach or duodenal ulcer YesNo
Digestive disorders YesNo
Arthritis YesNo
Glaucoma YesNo
Cosmetic surgery YesNo
Hearing loss/hearing aid YesNo
Head or neck injuries YesNo
Epilepsy, Convulsions (seizures) YesNo
Viral infections and/or cold sores YesNo
Hives, skin rash, hay fever YesNo
Venereal disease YesNo
Hepatitis (Type : )YesNo
HIV/AIDS YesNo
Tumor, abnormal growth YesNo
Radiation or chemotherapy YesNo
Emotional problems/psychiatric treatmentYesNo
Antidepressant medication YesNo
Alcohol / drug dependency YesNo

Are you :
Often exhausted or fatigued YesNo
Subject to frequent headaches YesNo
A smoker, how many : YesNo
Male – prostate disorders YesNo
Female :
Taking birth control pills YesNo
Pregnant, due date :
YesNo

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) when?
Yes No
Periodontal (gum) treatment, when?   
Yes No
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 ? YesNo When ?
Is your present denture a problem ? YesNo Describe :
Are you satisfied with the chewing ability ? YesNo

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 :
(Your digital signature (full name) is as legally binding as a physical signature.)