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Patient Registration Form

Print blank form to fill by hand
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 :
Preferred Name :
*Date of Birth :
Sex : Male Female
*Home Address
City :
State :
Zip :
APT# :
*Email address :
Marital Status : Single Married Partnered Divorced/Separated Widowed
*Home Phone : ( )- -
Work Phone: ( )- - -
Cell Phone: ( )- -
Employer :
Employer Address:
City :
State :
Zip :
APT# :
How long there ?
Occupation :
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 :
Previous dentist :
Person responsible for account :

Spouse Information

His / Her name :
Birthday :
Work Phone: ( )- - -
Cell Phone: ( )- -

Relative or friend not living with you

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

Insurance information

Primary insurance
Dental coverage? Yes No
Insurance Co.:
City :
State :
Zip :
Phone : ( )- -
Group# :
Insured’s name :
Relationship :
Birthday :
Insured’s ID :
Insured’s employer
Employer Address:
City :
State :
Zip :
APT# :
Secondary insurance
Dental coverage? Yes No
Insurance Co.:
City :
State :
Zip :
Phone : ( )- -
Group# :
Insured’s name :
Relationship :
Birthday :
Insured’s ID :
Medical insurance
Insurance Co.:
City :
State :
Zip :
Phone : ( )- -
Group# :
Insured’s name :
Relationship :
Birthday :

Medical History

Physician’s Name :
Telephone home : ( )- -
Date of last visit :
Your current physical health is :
Good Fair Poor
Ever been hospitalized? Yes No
Do you drink alcohol? Yes No
Do you use drugs? Yes No
Any trouble with prior surgeries? Yes No
Are you currently under the care of a physician? Yes No
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
Have you ever taken Fosamax, or any other bisphosphonate? Yes No
Have you ever taken Phen-fen? Yes No
Is your mouth dry? Yes No
Do you have any type of hearing impairment? Yes No
Do you wear contact lenses? Yes No
Please list all medication/drugs that you are currently taking :
For women :
Are you using a prescribed method of birth control? Yes No
Are you pregnant?     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 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 Angina Yes No Head injury
Yes No Heart Disease 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
Yes No Herpes / Fever blisters Yes No High blood pressure
Yes No HIV Yes No Kidney problems
Yes No Liver disease Yes No Low blood pressure
Yes No Lupus Yes No Sickle cell disease / Traits
Yes No Sinus problems Yes No Stroke
Yes No Thyroid problems Yes No Tuberculosis (TB)
Yes No Ulcers Yes No Aneurysm
Yes No Respiratory Problem Yes No STD
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 Codeine
Yes No Tetracycline Yes No Dental anesthetics
Yes No Other Yes No Erythromycin
Yes No Latex Yes No Any Nuts
Please list any other drugs / Materials that you are allergic to :

Payment is due in full at the time of treatment

Unless prior arrangements have been approved.
* 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?
Date of your last dental visit :
Date of your last dental cleaning :
Date of last full mouth series of x-rays :
Are you currently in pain? 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 hot, cold, sweets or anything else? Yes No
Any problems with Jaw? Yes No
Mouth breather? Yes No
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
Does food tend to become caught between your teeth? Yes No
Do your gums often bleed when you brush your teeth ? Yes No
Have you ever had jaw surgery or a broken jaw ? Yes No
Do you clench or grind your teeth while awake or asleep? Yes No
Do you snore ? Yes No
Do you feel very nervous about having dental treatment? Yes No
Have you ever had an upsetting experience in a dental office ? Yes No
Is there anything else about having dental treatment that bothers you ? Yes No
Do you expect to eventually lose your teeth? Yes No
Would you like to discuss improving your smile at today's appointment? Yes No
Are you dissatisfied with the appearance of your teeth ? Yes No
Do you feel your teeth are crowded or crooked ? Yes No
Do you feel your teeth are yellow, dark or stained ? Yes No
Do you feel your smile could be improved ? Yes No
If yes to any of these questions, please explain
Are you happy with the way your smile looks? Yes No
If not, what would you change?
Have you ever had
Yes No Orthodontic treatment Yes No Oral surgery
Yes No Periodontal treatment Yes No Worn a bite plate

* To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. If deemed advisable, I grant permission for my physician to be contacted for details and advice. For evaluation or teaching purposes I authorize the use of my radiographs or photographs. Authorization is also given for dental treatment to be rendered by the dentist and office staff, and I will assume financial responsibility.